Fitness for Duty/Return to Work evaluations

[Shikima]

Has any one had experience with these type of evaluations?

I was recently asked to complete a fitness for duty evaluation to identify psychological conditions which would prevent a person to work. This is the result of mediation and the person already has psychological evaluation completed which was not good enough for the mediation committee.

I came across this page and I'm thinking - this doesn't seem in the realm of general psychiatry, but more forensic in nature. http://www.psycheval.com/assessing_ffd_rtw.shtml

Can anyone shed more light on this for me?

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[mgdsh]

It is more forensic in nature as you noted. I've handled a few of these that were slam dunks (both with fit for duty and unfit for duty). Both of these also came with collateral data to review which helped significantly and also added to the scope of work/charge.

 

[Shikima]

It appears there is a considerable amount of organizational psychology involved for making these determinations such as work collateral and personality testing using NeuroPsych testing. Perhaps some of the psychologists can render an opinion about these kinds of evaluations.

 

[F0nzie]

Sounds like questions I don't know the answers to.

 

[erg923]

It appears there is a considerable amount of organizational psychology involved for making these determinations such as work collateral and personality testing using NeuroPsych testing. Perhaps some of the psychologists can render an opinion about these kinds of evaluations.

Fitness for duty as a....?

Pilot? Police officer? Neurosurgeon? Forklift operator? Sales clerk? Secretary? Backroom stocker at Walmart?

Obviously, some of these are straightforward and some require alot of specialized knowledge of the job and the cognitive skills needed to do the work safely and effectively.

I also would suggest having the person who is being examined (who is not your "patient" in these cases) sign a document that acknowledges that you will be communicating with their employer and that this communication will not be disclosed to the them.

 

[wolfvgang22]

Are you being paid to complete such an evaluation?

 

[heyjack70]

These evaluations are serious business. They are inherently oppositional because if you find the person unfit they can't go back to work and earn a living, so they want to present as healthy as possible. It usually involves significant record review, possible referral for psych testing, probably at least a 2-3 hour in depth psych evaluation, then many more hours writing a clear and useful report. You should not be billing insurance. You should get paid in advance for your time. And depending on location the hourly rate you could charge would be between $250-$600. I wouldn't do it without forensic experience. Agree the person must sign a release that the report will go to their job as the employer will likely be paying for the evaluation.

 

[whopper]

I've done a few. They are forensic. You don't have to be a forensic psychiatrist but then again you don't have to be a child psychiatrist and prescribe to children. It's allowable in a legal sense but do so at your own risk and I wouldn't recommend it.

If you are the clinical doctor treating the patient your ability to do such an evaluation is greatly hindered on the following points. 1-You are the treating doctor. Nothing can get by to the employer without the patient's okay. Further, have what is legally defined as a "fiduciary responsibility"to be for the patient causing you to be biased. 2-Your payment structure (insurance) likely only allows to do a fitness for duty evaluation based on clinical evaluations of the patient that do not 100% apply to the work setting because they only reimburse you to heal the patient, not evaluate them for professional reasons. If you are charging out of pocket, the patient is technically your boss and again you have the problem in #1.

E.g. in a potential fitness for duty evaluation I might want to review all of the patient's bank and credit card statements to see if they could manager their finances. This is something a clinical doctor usually doesn't do.

Sometimes the treating doctor is asked to do a fitness for evaluation. Such requests could be inappropriate for the reasons mentioned above. In such a case your responsibility is to treat the patient, not objectively rate their ability to work in a specific setting that could literally go against your patient's wishes and possibly even cause them harm in some sense (e.g. they are depressed, you think they can't work, you write it down--> patient loses job and now is mad at you and accuses you of violating your Hipocratic Oath).

3-When doing fitness for duty evals, you are required to address what the responsibilities are for the job. E.g. you might have to go to the place of work, understand the technicals, etc. This is not compatible with an office or hospital based practice where you treat people.

If asked to do a fitness for duty evaluation and you're the treating doctor either 1-say you can't do it for the reasons above, or 2-if you do it, specifically state it is a biased evaluation because you are the treating doctor and that you can't really do one that is objective by forensic standards.

 

[Shikima]

Fitness for duty as a....?

Pilot? Police officer? Neurosurgeon? Forklift operator? Sales clerk? Secretary? Backroom stocker at Walmart?

Obviously, some of these are straightforward and some require alot of specialized knowledge of the job and the cognitive skills needed to do the work safely and effectively.

I also would suggest having the person who is being examined (who is not your "patient" in these cases) sign a document that acknowledges that you will be communicating with their employer and that this communication will not be disclosed to the them.

I don't know the details other than the office was in contact by a lawyer who said this was a one-time evaluation as apart of an agreement during mediation.

 

[Shikima]

Are you being paid to complete such an evaluation?

I would be, but the risk to justify in saying that someone wouldn't go 'postal' in the workplace is too great.

 

[Shikima]

I've done a few. They are forensic. You don't have to be a forensic psychiatrist but then again you don't have to be a child psychiatrist and prescribe to children. It's allowable in a legal sense but do so at your own risk and I wouldn't recommend it.

If you are the clinical doctor treating the patient your ability to do such an evaluation is greatly hindered on the following points. 1-You are the treating doctor. Nothing can get by to the employer without the patient's okay. Further, have what is legally defined as a "fiduciary responsibility"to be for the patient causing you to be biased. 2-Your payment structure (insurance) likely only allows to do a fitness for duty evaluation based on clinical evaluations of the patient that do not 100% apply to the work setting because they only reimburse you to heal the patient, not evaluation them for professional reasons. If you are charging out of pocket, the patient is technically your boss and again you have the problem in #1.

E.g. in a potential fitness for duty evaluation I might want to review all of the patient's bank and credit card statements to see if they could manager their finances. This is something a clinical doctor usually doesn't do.

Sometimes the treating doctor is asked to do a fitness for evaluation. Such requests could be inappropriate for the reasons mentioned above. In such a case your responsibility is to treat the patient, not objectively rate their ability to work in a specific setting that could literally go against your patient's wishes and possibly even cause them harm in some sense (e.g. they are depressed, you think they can't work, you write it down--> patient loses job and now is mad at you and accuses you of violating your Hipocratic Oath).

3-When doing fitness for duty evals, you are required to address what the responsibilities are for the job. E.g. you might have to go to the place of work, understand the technicals, etc. This is not compatible with an office or hospital based practice where you treat people.

If asked to do a fitness for duty evaluation and you're the treating doctor either 1-say you can't do it for the reasons above, or 2-if you do it, specifically state it is a biased evaluation because you are the treating doctor and that you can't really do one that is objective by forensic standards.

Thanks for confirming this. I did a lot of reading up on this today and eventually declined due to the risk and lack of training in this area. The amount earned for one of these evaluations isn't worth the risk and going to court over.

 

[whopper]

I don't know the details other than the office was in contact by a lawyer who said this was a one-time evaluation as apart of an agreement during mediation.

So it seems they want you as a non-treating evaluator. Again you could do this but do you want to step into it? I do know physicians without forensic training that do this type of thing. Many of them don't do it right but they're also practicing in sheriff Bubba with the mirror-sun glasses hick-town so they get away with it, just like the local colleges are discriminating against the local minorities and are getting away with it too.

But if you're in an area where there is a chance where the opposing side hired someone with real forensic training expect that guy to work with the lawyer on doing a cross-examination meant to utterly destroy you on the witness stand and you not having the training to stand up to them.

Forensic evaluations make good money but it's hard money. E.g. it's the same amount of concentration and intensity as playing chess against someone that's very good where there are real stakes such as say for example 10% of your yearly salary.

Here's what I mean by easy money: you see patient, patient wants a refill but is otherwise fine. Both of you talk about some of the TV shows you are watching, you ask the patients if their kids are alright, the remark on the pics of your kids on your desk, both of you smile, and you write their prescription.

EASY MONEY!

Here's what I mean by hard money: I do a fitness for evaluation on a guy with paranoid personality disorder to the degree where his employer doesn't want him at work cause sooner or later he gets into a fight with everyone he works with. So I do the evaluation, I have to interview all the coworkers, find out what the job requires (so I now have to end up reading a manual that's over 200 pages in about 1-2 days), but not just read it, really understand it to the degree where if I'm on the witness stand and they quiz me on it I'll be able to answer the questions, 3-I interview the guy....

and voila I find that the guy does have paranoid personality disorder and he does cause frequent workplace disruptions, and his employer only has to make accommodations if they are "reasonable." His employer really can't do that because the guy's job forces him to work with other people.

So I give the report, and now his lawyer is all ticked off because the lawyer told me he hired me to write a report telling that the guy is fine when he is not. I tell the lawyer that he knows as well as I do that I'm not supposed to write a false report. Then the lawyer's all pissed off, and then the guy with the paranoid personality disorder is now accusing me of being with cahoots with the employer (it's his paranoia) and sues me.

This is HARD MONEY! Each step of this process is full of effort, wrought with headaches and frustration. Yes you make more per hour but most people would've just did the easier thing.

BTW: the above really did happen to a close friend of mine. The legal expenses from the lawsuit were about $300K, and mind you this guy IS A FORENSIC PSYCHIATRIST. Further had he done it privately his malpractice insurance wouldn't have covered it because the paranoid-personality guy didn't sue him for malpractice. He sued him for a civil rights violation stating that as his "doctor" he violated the guy's civil rights by coming up with an opinion that was detrimental to him.

My friend was thankfully covered because he did it through the university so the university had to pay for his legal defense.

 

[PikminOC]

Great thread shikma!

 

[Shikima]

Whopper, I take my hat off to you. I just couldn't do it, because I don't have the training and I don't need the litigation that comes with it all.

I do remember one job that I did interview with; It was a collaborative effect between the local hospital and the local univ where they needed psychiatric coverage. The univ wanted me to do eval's on the students that were on diversion for a variety of reasons and the document would be presented to their internal 'court'. They didn't want to pay extra for it, just apart of the salary expectations.

Now I'm glad I don't have that job either, althought I admittly was disappointed at the time when it didn't work out.

 

[whopper]

In forensic fellowships it's typical part of the training to be cross-examined in the most intense methods. Imagine having a crowd of people all watching you and the lawyer on the other side finds one spelling error on a report of 50 pages and then spending 20 minutes on this one spelling error alone in an attempt to discredit you, all the while screaming at you

And then there's a whole bunch of legal tricks the lawyers could drum up. E.g. they sometimes ask the psychiatrist, "Is the DSM IV or V considered an authoritative textbook in your field?"

If you answer yes, they can then pull out the book and start asking you asinine questions such as "Doctor, please state criteria B of the diagnostic criteria for PTSD." If you state you don't have it memorized, "Well doctor it seems to me that you don't even know the criteria of what you STATED is an AUTHORITATIVE TEXT in your field!"

After getting your butt kicked and handed to you while sweating in your $1000 suit for about an hour every few weeks you start figuring out how to play their game and develop a thick skin to this.

(For those just in case you are wondering how you should answer).

Simply state "no." When asked if the book is authoritative.
When asked to elaborate, and don't volunteer this information unless asked, here's a type of answer you could give. "The DSM-V while highly respected in the field is not authoritative. The book itself even states it is mostly for guidelines and research purposes and should not be seen as an end-all-be-all authoritative source."

And when you start working in the locality for several months to years you start figuring out what each lawyer typically uses as a line of attack, or what the judges are looking for, and could accommodate your answers for the appropriate audience. By then you will develop a familiarity with many of them, even friendships.

Yes I have had some lawyer friends grill me on the stand. It is truly the act of a professional in the field to not take this personally. We stayed friends before, during, and after the time he grilled me. If anything he proved to me that if I ever got in trouble I'd want him as my lawyer.

 

[EatSleepForensics]

So it seems they want you as a non-treating evaluator. Again you could do this but do you want to step into it? I do know physicians without forensic training that do this type of thing. Many of them don't do it right but they're also practicing in sheriff Bubba with the mirror-sun glasses hick-town so they get away with it, just like the local colleges are discriminating against the local minorities and are getting away with it too.

But if you're in an area where there is a chance where the opposing side hired someone with real forensic training expect that guy to work with the lawyer on doing a cross-examination meant to utterly destroy you on the witness stand and you not having the training to stand up to them.

Forensic evaluations make good money but it's hard money. E.g. it's the same amount of concentration and intensity as playing chess against someone that's very good where there are real stakes such as say for example 10% of your yearly salary.

EASY MONEY!

Here's what I mean by hard money: I do a fitness for evaluation on a guy with paranoid personality disorder to the degree where his employer doesn't want him at work cause sooner or later he gets into a fight with everyone he works with. So I do the evaluation, I have to interview all the coworkers, find out what the job requires (so I now have to end up reading a manual that's over 200 pages in about 1-2 days), but not just read it, really understand it to the degree where if I'm on the witness stand and they quiz me on it I'll be able to answer the questions, 3-I interview the guy....

and voila I find that the guy does have paranoid personality disorder and he does cause frequent workplace disruptions, and his employer only has to make accommodations if they are "reasonable." His employer really can't do that because the guy's job forces him to work with other people.

So I give the report, and now his lawyer is all ticked off because the lawyer told me he hired me to write a report telling that the guy is fine when he is not. I tell the lawyer that he knows as well as I do that I'm not supposed to write a false report. Then the lawyer's all pissed off, and then the guy with the paranoid personality disorder is now accusing me of being with cahoots with the employer (it's his paranoia) and sues me.

This is HARD MONEY! Each step of this process is full of effort, wrought with headaches and frustration. Yes you make more per hour but most people would've just did the easier thing.

BTW: the above really did happen to a close friend of mine. The legal expenses from the lawsuit were about $300K, and mind you this guy IS A FORENSIC PSYCHIATRIST. Further had he done it privately his malpractice insurance wouldn't have covered it because the paranoid-personality guy didn't sue him for malpractice. He sued him for a civil rights violation stating that as his "doctor" he violated the guy's civil rights by coming up with an opinion that was detrimental to him.

My friend was thankfully covered because he did it through the university so the university had to pay for his legal defense.

Hang on a second here - let's not dramatize. As someone who regularly performs fitness for duty examinations and is also employed by a national group that does workplace threat assessment, I must say that scenarios like the one you've described here are extremely rare and are not representative of most FFD exams. This is quite dramatic and exceedingly few FFD cases end in the kind of courtroom (or much more likely, deposition) testimony you're talking about. First, there are no attorneys involved in most FFD scenarios. Instead, the examinations are ordered and performed through the employer's disability management system on employees who want to return to work and who are most likely ready to return, at least to modified duty. For those who aren't ready to return, most are not unfit due to qualifying as a direct threat, and successful challenges to opinions that someone is a direct threat are rarely successful. "Fitness for duty" is also a HIGHLY variable referral with respect to precisely what you're being asked to address, often much more akin to a disability examination. This depends greatly upon the employer and system. I agree with "heyjack"'s take on this: yes, these exams are "forensic" and involve the additional elbow grease and attention to detail that goes along with it. But, most of them are not scenarios with a very high degree of liability and very very few are likely to end in any sort of situation where the examiner is pitted against exacting cross-examination.

 

[whopper]

most of them are not scenarios with a very high degree of liability

Agree with what you stated on a factual level but the description you mention is part of the issue I brought up--a lack of understanding how this system works for the non-psychiatric physician, and given this should they dip their feet into forensic waters?

I have been in evaluations that have gone to court-yes unlikely it could become adversarial but it could become that, just like regular clinical practice is something that is likely to not something that will end up with the doctor going to court.

But look at it from a long-term level. Several recommend that doctors practice as if everything they do could end up in court, not to be defensive for the sake of being defensive but because several aspects of what the court wants to see in doctors simply is good practice. E.g. good documentation, appropriate and valid diagnosis and treatment, etc. Defensively, however, it is supposed to be realistic to anticipate being sued on the order of every few years for some docs depending on the specialty. (I don't know what it is for psychiatry-offhand).

Having seen several poorly written fitness-for-duty evals done by non-forensic psychiatrists, riddled with easy errors a trained forensic psychiatrist would not make, coupled with the above and seeing a friend of mine go through a malicious lawsuit? Also bear in mind that the FFD could be for a personality disorder-a cluster B PD and all psychiatrists know, forensic or not,-that emotions could run high especially if you don't give an opinion the evaluee wants. I don't think I'm being dramatic.

Some examples of the easy mistakes are 1-eval written where the physician was not supposed to be the treating doctor and wrote that the defendant was his "patient." 2-While cross examined, the non-treating doctor didn't understand that what was discussed between him and the evaluee was not supposed to be protected.

I do agree with the content of your post. I just got a different take on it.

 

[F0nzie]

Defensively, however, it is supposed to be realistic to anticipate being sued on the order of every few years for some docs depending on the specialty. (I don't know what it is for psychiatry-offhand).

I heard once every 30 years. No sources to back it up.

 

[whopper]

I did a search where I'm at (currently working in the local county jail as a contractor through SLU), but there's so many filters on the search engine I gave up.
More germane to what I wrote, say one were to be sued or through a review of some sort (e.g. a medical board query) and they understood the system and knew they did nothing wrong. That in and of itself could be stressful despite the confidence you are in the right.

Then imagine going through something for writing a report for a legal situation when you've never been trained on how the system works, understand it yourself or know the pitfalls where a gotcha adversary could nail you. Like I said it's like a general psychiatrist prescribing to children. You could do it, but I wouldn't recommend it.

I've been in talks with private psychiatrists about this and I think they could do this type of thing without a fellowship if someone who knew how to do it guided them and was available in case something not expected happened.

Even after I completed fellowship I still considered myself green (Still do). The fellowship really just opened the door on this different area, and that fellowship is one of the best ones with top guys in the field.

But in EatSleepForensic's defense, all of his/her comments are factually correct. The likelihood of being nailed is small.

 

[TexasPhysician]

In this paranoid personality d/o case, in your opinion what determines the difference in not fit for duty vs just a poor fit for that particular job?

I'd argue that unless the paranoia is to the degree of delusional constituting a threat, then the patient is fit for duty. He just isn't a good fit for that job. It is not our job to fit clients into the best job for them or make firing decisions for corporations.

I would think our job is determining if the patient is stable enough to perform that job at that time.

Could I not write the report saying the patient has paranoia, but he currently can perform the job safely. It is the corporations job to monitor his functioning as the patient may develop symptoms that make him unfit in the future.

After all, we don't foretell the future either.

I'm not saying your view is wrong, but really arguing to find out where my reasoning is flawed.

 

[Therapist4Chnge]

Thanks for confirming this. I did a lot of reading up on this today and eventually declined due to the risk and lack of training in this area. The amount earned for one of these evaluations isn't worth the risk and going to court over.

If anyone is thinking of doing these, they should definitely be mentored on some cases first so they can learn the in & outs, though a fellowship or more serious mentorship is the better choice. I do them for a couple of very specific areas, though I pass on everything else because it is either our of my wheelhouse or there are red flags that no amount of money will change. While any case you see many end up in court (including regular clinical work), poorly done work will put you at a much greater risk. It is important to know what you know and know what you don't.

Solid info given by heyjack70 and others.

 

[whopper]

the difference in not fit for duty vs just a poor fit for that particular job?

Good question but I wasn't the guy who did the evaluation, and I didn't get the details on the specifics you asked about. It was a friend of mine--who was forced to go to court for several days out of his own vacation time.

 

[Therapist4Chnge]

Like clockwork…I just received a referral that isn't specifically a fitness for duty eval, but I suspect that is what at least one side wants to use it for. There is a clear medical need for the eval and the referral fits that need, so I'm taking the referral as a clinical eval. I have a disclaimer I include in all of my clinical evals that speak to the differences between clinical evals and forensic evals (which includes FFD..at least in my eyes) and explicitly describes the intended use of the eval and the limits of the evaluation in regard to applicability in other settings. I can still get dragged into a court case, but I am at least clear with the patient of my role and the reason provided to me for their referral, so if I'm later questioned about this I have documentation that backs me up.