How do letters make you feel?

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F0nzie

F0nzie

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Letters for permissions, excuses, avoidance of liability... Restore my gun rights! Make me my own payee! Write a letter so I can get out of student loans! Diagnose me with X! Remove this diagnosis! Write a letter that says I can only work 20 hours! My boss needs a letter saying I cannot do X!

What happened to personal responsibility and why is that authority consistently assigned to us?


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Yeah, I tell people "tough S***" .... I don't agree and I won't write such a letter. Sick leave is given in 6 week blocks only.

I also give them the opportunity to seek out a 2nd opinion else where.
 
So yesterday a woman came in to see me for a fifteen minute med check. I'd never seen her before. She had been evaluated by another psychiatrist. She asks for a letter to take to her boss to say she can't work. I can't assess that in 15 minutes. I tell her that. So now it's my fault she's going to get fired.


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I've never liked those requests. Fortunately I haven't encountered it much in my child and adolescent fellowship. Last year in my adult clinic, however, I remember getting a lot of these. I had a couple of patients request a letter from us stating that they required a therapy pet, so they could get out of paying a deposit, or simply allowing them to own a pet if their landlord prohibited it. My attending actually had a prepared template for such a request, which simply said something to the effect of "This person states that they require a pet for therapeutic purposes. Thank you for your consideration." Nothing in the letter implied that the doctor agrees with the patient, and it basically left the decision-making up to whoever ultimately makes that decision anyway. 😉
 
F0nzie said:
Letters for permissions, excuses, avoidance of liability... Restore my gun rights! Make me my own payee! Write a letter so I can get out of student loans! Diagnose me with X! Remove this diagnosis! Write a letter that says I can only work 20 hours! My boss needs a letter saying I cannot do X!

What happened to personal responsibility and why is that authority consistently assigned to us?


Sent from my iPhone using SDN mobile app
Click to expand...
Hey Fonz, can you write me a letter to get out of my student loans? I owe a ton and that would really help me out. Didn't even know about that option, but it sounds great. I have severe severe severe emotional distress every time I write them a check. It is just a horrible affliction. 😉
 
My stress levels get super high when I'm constantly seeing unstable patients while trying to put out fires left and right. Add to that all the requests and paperwork for disability, nursing homes, employers... and how angry and hostile people can get when you do not fulfill their requests. To top it off, the threatening and aggressive stances from them and being told to go #%^* myself... Ugh I can't do this anymore 🙁


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F0nzie said:
My stress levels get super high when I'm constantly seeing unstable patients while trying to put out fires left and right. Add to that all the requests and paperwork for disability, nursing homes, employers... and how angry and hostile people can get when you do not fulfill their requests. To top it off, the threatening and aggressive stances from them and being told to go #%^* myself... Ugh I can't do this anymore 🙁


Sent from my iPhone using SDN mobile app
Click to expand...
Sounds like you need a letter excusing you from work.

To Whom It May Concern:
I am writing this letter at the bequest of Dr. Fonzie who is a current colleague of mine. Due to his history of dealing with difficult patients, he would greatly benefit from having a cat to help lower his anxiety and distress. Therefore, I am recommending that he be allowed to have a cat for therapeutic reasons.
If you have any questions, please feel free to contact me.​
Sorry, wrong letter. Oh well, you should probably just get a cat and get back to work.
😛
 
smalltownpsych said:
Sounds like you need a letter excusing you from work.

To Whom It May Concern:
I am writing this letter at the bequest of Dr. Fonzie who is a current colleague of mine. Due to his history of dealing with difficult patients, he would greatly benefit from having a cat to help lower his anxiety and distress. Therefore, I am recommending that he be allowed to have a cat for therapeutic reasons.
If you have any questions, please feel free to contact me.​
Sorry, wrong letter. Oh well, you should probably just get a cat and get back to work.
😛
Click to expand...
I was going to write a letter exempting him from writing letters, but the cat is probably a better idea. Unless he can get a dog.

I love my dog.
 
F0nzie said:
Letters for permissions, excuses, avoidance of liability... Restore my gun rights! Make me my own payee! Write a letter so I can get out of student loans! Diagnose me with X! Remove this diagnosis! Write a letter that says I can only work 20 hours! My boss needs a letter saying I cannot do X!

What happened to personal responsibility and why is that authority consistently assigned to us?
Click to expand...
Is this at the CMHC or in your pp? At my CMHC we have a "team-based approach" to these sorts of requests. The patient has to make the request to the case manager and we'll discuss it as a team. If it is felt appropriate, the case manager will draft the letter. If it needs a psychiatrists signature the psychiatrist will sign but only when consensus has been reached. This prevents splitting, creates a consistent policy, creates a lag between the request and an answer, and means that the psychiatrists don't have to waste time writing these letters.

Personally I am quite happy to write a letter supporting people having emotional support animals, particularly cats. Hell, that may be the most effective thing I can do. But for the most part I don't touch disability and won't provide moral exculpation for people.

In private practice, my understanding is that it can be harder to say no to requests because you're running a business and probably don't want to lose patients. At least you can charge however much you like for writing these letters.
 
I always assumed this was the high-yielding easy stuff, like popcorn at a movie theatre. It's usually just a signature and you can charge pretty much whatever you want.
 
F0nzie said:
My stress levels get super high when I'm constantly seeing unstable patients while trying to put out fires left and right. Add to that all the requests and paperwork for disability, nursing homes, employers... and how angry and hostile people can get when you do not fulfill their requests. To top it off, the threatening and aggressive stances from them and being told to go #%^* myself... Ugh I can't do this anymore 🙁


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Click to expand...

This is how I've been feeling the past few months. I feel very jaded as it seems I'm skeptical of most every patient because everyone comes in with an agenda of what they want and they aren't really wanting to get better.

I'm also getting very specific requests, particularly from veterans (not at the VA) asking for specific wording. I'm pretty sure there's a lawyer out there coaching them on saying if they can get a doctor's writing saying they have _____ and that they can't tolerate the treatment because _____. I get more skeptical because I see people with a lot of incentive to be sick, don't want to comply with actual treatment (like therapy, going to work, getting out of the house, etc.) but give every reason why they can't. Then I expect they'll have the most dramatic side effects from SSRIs and want "a note for work" that says they're sick because of medication side effects.
 
smalltownpsych said:
Sounds like you need a letter excusing you from work.

To Whom It May Concern:
I am writing this letter at the bequest of Dr. Fonzie who is a current colleague of mine. Due to his history of dealing with difficult patients, he would greatly benefit from having a cat to help lower his anxiety and distress. Therefore, I am recommending that he be allowed to have a cat for therapeutic reasons.
If you have any questions, please feel free to contact me.​
Sorry, wrong letter. Oh well, you should probably just get a cat and get back to work.
😛
Click to expand...

If I can bring the cat to work I'm pretty sure this will help. Can you rewrite the letter?


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F0nzie said:
If I can bring the cat to work I'm pretty sure this will help. Can you rewrite the letter?


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Click to expand...
I'm thinking you just call it a therapy cat, then while you are talking about side effects, symptoms, and other more medical related issues, the cat can handle the paychotherapy. The great part is you bill for the cats services and then pay them with cheap cat food. Heck, you could even splurge by giving them fancy feast and you'll still be making a good profit. Much better margins than equine therapy and it is much more difficult to get a horse in your office.
 
F0nzie said:
My stress levels get super high when I'm constantly seeing unstable patients while trying to put out fires left and right. Add to that all the requests and paperwork for disability, nursing homes, employers... and how angry and hostile people can get when you do not fulfill their requests. To top it off, the threatening and aggressive stances from them and being told to go #%^* myself... Ugh I can't do this anymore 🙁


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Click to expand...

You're getting out of that job, right? Community MH is hard enough, but it sounds like you're at a particularly bad place.
 
Can I write myself a letter to get out of my student loans? Or maybe we can start a "you scratch my back, I'll scratch yours" type of thing.


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Usually such requests are asking for the psychiatrist to provide an opinion on the capability or disability of the patient in regard to some functional aspect for an administrative or legal purpose. Such evaluations are best performed by psychiatrists with forensic training in a non-clinical setting. Clinicians can often find transitioning from therapeutic to forensic roles difficult. Whereas, independent forensic evaluations are unencumbered by the therapeutic relationship, allowing for more objectivity and focus on the question at hand. Thus, I do not comment on patients’ capacity for administrative or legal purposes. In cases where such opinion is requested, I provide an appropriate referral.
 
Guyton said:
Usually such requests are asking for the psychiatrist to provide an opinion on the capability or disability of the patient in regard to some functional aspect for an administrative or legal purpose. Such evaluations are best performed by psychiatrists with forensic training in a non-clinical setting. Clinicians can often find transitioning from therapeutic to forensic roles difficult. Whereas, independent forensic evaluations are unencumbered by the therapeutic relationship, allowing for more objectivity and focus on the question at hand. Thus, I do not comment on patients’ capacity for administrative or legal purposes. In cases where such opinion is requested, I provide an appropriate referral.
Click to expand...
So you're saying I can't have my therapy cats?
 
splik said:
http://gomerblog.com/2016/03/borderline-personality-disorder/
Click to expand...
🤣
This was one of the best articles I have read in a while. I usuaully don't laugh out loud when I read an article, but this one got me. I'm printing out for my colleagues.
"I was amazed at his level of clinical detachment."
hqdefault.jpg

If someone teaches this cat to nod and say "hmmm" and "interesting", we might all be in trouble.
 
I'll do it sometimes, but I'm never happy about it. I never do it on the first appointment.

"I have a dog where dogs are not allowed. It calms me down. Can you tell my landlord it's a therapy dog?"

"My child has missed ___ days of school because of ___. We need you to excuse them for all of those days." Or they want endless homebound status. Nope, nope nope.
 
milesed said:
I'll do it sometimes, but I'm never happy about it. I never do it on the first appointment.

"I have a dog where dogs are not allowed. It calms me down. Can you tell my landlord it's a therapy dog?"

"My child has missed ___ days of school because of ___. We need you to excuse them for all of those days." Or they want endless homebound status. Nope, nope nope.
Click to expand...

I never heard of homebound until here. I get what it is, but I've never heard of homebound for, "anxiety", especially in a patient who also steals things.
 
smalltownpsych said:
🤣
This was one of the best articles I have read in a while. I usuaully don't laugh out loud when I read an article, but this one got me. I'm printing out for my colleagues.
"I was amazed at his level of clinical detachment."
hqdefault.jpg

If someone teaches this cat to nod and say "hmmm" and "interesting", we might all be in trouble.
Click to expand...
Might be easier to train cats than residents...

Hmm.
 
F0nzie said:
Letters for permissions, excuses, avoidance of liability... Restore my gun rights! Make me my own payee! Write a letter so I can get out of student loans! Diagnose me with X! Remove this diagnosis! Write a letter that says I can only work 20 hours! My boss needs a letter saying I cannot do X!

What happened to personal responsibility and why is that authority consistently assigned to us?


Sent from my iPhone using SDN mobile app
Click to expand...

This is just a doctor thing in general. People are trying to get letters from doctors all the time to get them out of stuff because they tend to carry authority.
 
milesed said:
"I have a dog where dogs are not allowed. It calms me down. Can you tell my landlord it's a therapy dog?
Click to expand...

I have always wondered why we have this kind of power over people business decisions/practices?

Personally, I would never have the gall assert that degree of third party control/persuasion over a persons (landlords') business.
 
Last edited:
erg923 said:
I have always wondered why we have this kind of power over people business decisions/practices?
Click to expand...

I'm not sure why this is so surprising. There's a whole field of psychiatry related to the intersection between the law and mental health, called forensic psychiatry.

So a person having murdered someone is less significant than a person wanting a dog in their apartment.

But they're both areas covered by the law. Granted therapy animals are currently treated differently than service animals. But it doesn't mean an apartment owner isn't concerned about legal action. People are sensitive to both public pressure and possible legal threats posed by unsettled areas of law, including the ADA. Courts are always looking to experts, whether its chemists, coroners, or psychiatrists. It makes sense for apartment owners to try to move responsibility for the decision to someone considered an expert in the area of the necessity of a particular intervention--I'm not saying you should like it. But it doesn't seem surprising.
 
birchswing said:
I'm not sure why this is so surprising. There's a whole field of psychiatry related to the intersection between the law and mental health, called forensic psychiatry.

So a person having murdered someone is less significant than a person wanting a dog in their apartment.

But they're both areas covered by the law. Granted therapy animals are currently treated differently than service animals. But it doesn't mean an apartment owner isn't concerned about legal action. People are sensitive to both public pressure and possible legal threats posed by unsettled areas of law, including the ADA. Courts are always looking to experts, whether its chemists, coroners, or psychiatrists. It makes sense for apartment owners to try to move responsibility for the decision to someone considered an expert in the area of the necessity of a particular intervention--I'm not saying you should like it. But it doesn't seem surprising.
Click to expand...
Yes. Exactly. And I'm not in forensic practice. Nor are most of the people who posted in this thread. That's the whole point.
 
I met this patient twice. Today she brings paperwork from her attorney. I have a friend who's an attorney who works on disability cases. It isn't what she wants to be doing, but the job market is tough out there for lawyers and she has a kid to support. So she does hourly work for a disability firm.

She told me that this paperwork I get handed is ridiculous and meaningless. That judges aren't stupid and know that you can't say someone can't work on first meeting them. And that what they're actually looking for is years' worth of consistent documentation.

So I am filling out this form. I said the dates I met the patient. I listed her diagnoses. I listed her meds. Everything else I'm filling in with "unknown", "unknown", "unknown."

She's gonna hate me.


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The worst ones are requests from Social Security disability BEFORE I've seen the patient. We don't fill these out at all, just send records.
Also the complaints we get, when we help get them better and the disability is stopped because of the improvements listed in records that they reported in session.
 
HooahDOc said:
I never heard of homebound until here. I get what it is, but I've never heard of homebound for, "anxiety", especially in a patient who also steals things.
Click to expand...

I get this request many times a week for patients with panic or social anxiety, occ for separation anxiety as well.
 
You mean there are people out there who do things to assign their own responsibilities to others? Who knew?
 
In all seriousness, I propose a simple test for the validity of a patient request that is outside of the established therapeutic frame:

If the patient has difficulty asking you for something, then they deserve your assistance.
 
Guyton said:
Usually such requests are asking for the psychiatrist to provide an opinion on the capability or disability of the patient in regard to some functional aspect for an administrative or legal purpose. Such evaluations are best performed by psychiatrists with forensic training in a non-clinical setting. Clinicians can often find transitioning from therapeutic to forensic roles difficult. Whereas, independent forensic evaluations are unencumbered by the therapeutic relationship, allowing for more objectivity and focus on the question at hand. Thus, I do not comment on patients’ capacity for administrative or legal purposes. In cases where such opinion is requested, I provide an appropriate referral.
Click to expand...

There are almost no forensic psychiatrists in my state, absolutely none in the region I work in, and 0% of those take insurance. So, what should I tell patients who ask for disability evals?
 
sunlioness said:
I met this patient twice. Today she brings paperwork from her attorney. I have a friend who's an attorney who works on disability cases. It isn't what she wants to be doing, but the job market is tough out there for lawyers and she has a kid to support. So she does hourly work for a disability firm.

She told me that this paperwork I get handed is ridiculous and meaningless. That judges aren't stupid and know that you can't say someone can't work on first meeting them. And that what they're actually looking for is years' worth of consistent documentation.

So I am filling out this form. I said the dates I met the patient. I listed her diagnoses. I listed her meds. Everything else I'm filling in with "unknown", "unknown", "unknown."

She's gonna hate me.


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Click to expand...

But if the judges aren't stupid, why are so many non-disabled people in SSDI? I'd say that 75-80% of the patients I've seen since starting my residency have been on SSDI. Most of them can't even tell me the diagnosis they're on it for. I heard somewhere that the federal government lacks a process for declining 3rd time SSDI applications. They have no doctors - or lawyers - on staff to review those repeat SSDI applications. That's why disability lawyers thrive.
 
My favorite is the DMV request for a letter commenting on the patient's ability to drive. I've sent letter to the DMV stating I am not qualified or don't have enough information to comment, and they've written back to me, demanding "more specific commentary upon the patient's ability to drive, including commentary upon the specific driving-related incident described below." I can't believe it. I started to actually feel bad for the patient, being harassed by the DMV to get a psychiatrist to comment on her driving ability. But, like, I'm going to take on legal responsibility for any patient's driving behavior? Yeah, right.
 
I'll write sometimes that there's nothing about X dx or med that would generally preclude driving.

The payee stuff gets me too. I've never watched these people handle money. I've never put them through a budgeting class? How the heck should I know?


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nancysinatra said:
My favorite is the DMV request for a letter commenting on the patient's ability to drive. I've sent letter to the DMV stating I am not qualified or don't have enough information to comment, and they've written back to me, demanding "more specific commentary upon the patient's ability to drive, including commentary upon the specific driving-related incident described below." I can't believe it. I started to actually feel bad for the patient, being harassed by the DMV to get a psychiatrist to comment on her driving ability. But, like, I'm going to take on legal responsibility for any patient's driving behavior? Yeah, right.
Click to expand...
We have 2 rehab groups here in town that have OTs who perform a specific driving assessment--so when it comes up, it's just "No letter until you've taken this test" and send the referral.
 
I'm unfamiliar with these requests from the psychiatric perspective, but I've received many of these requests while rotating on off-service rotations from hospitalized patients and/or their families. One patient's wife was actually requesting 6-8 weeks of FMLA leave because her husband was getting "heart surgery" a.k.a. a pericardiocentesis. When I tried to explain that this was not, in fact, heart surgery, that the procedure would likely not require 6-8 weeks of recuperation, and that she almost certainly would not be required to stay at home to care for him to the extent that she should miss work to do so, all I got was blank looks from both her and the patient. I just gave up and punted the form to the cardiology service. It also probably didn't help that she had already taken time off to "take care of him" even though he was in an inpatient medicine ward which certainly did not require her contribution.

Some of my colleagues said "just sign the form... who cares." On the one hand, I somewhat agree with them. I get it - she's worried about her husband and wants to be there for him. On the other hand, I get completely frustrated with these requests on principle and don't want to be complicit in them. If people want to try and fish for medical reasons to not be an independent and self-sustaining human being, then by all means they should go for it. But I don't feel comfortable putting my name on these dubious requests, and I feel like an ass for not agreeing to them when the only thing required of me is my signature on a bureaucrat's form.
 
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