Patient Asks for Psychiatrist to Complete Short-Term Disability Paper

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As the treating psychiatrist, what do you do?

How do you determine the patient's function at work?

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[Armadillos]

I pretty much never do long term disability stuff, but I’m much less critical when comes to short term disability. So long as patient isn’t raising huge malingering flags and they clinically appear symptomatic, I tend to trust their assessment of how well they are or aren’t functioning at work.

 

[psyxh]

I have a general rule that if a person meets the nebulous requirements of STD or prolonged FMLA, they should be spending that time in more intensive treatment (e.g. IOP/PHP).

Sent from my SM-N950U using SDN mobile

 

[PsyDr]

Should probably read the AMA's Guides to Causation, and at least know that there are some professional guidelines indicating a treating provider should not be doing this.

 

[FlowRate]

Should probably read the AMA's Guides to Causation, and at least know that there are some professional guidelines indicating a treating provider should not be doing this.

Aware of this but unfortunately encouraged by my attendings to do it anyway for patients who are deserving.

I have a couple of patients who I really don't think will ever be able to work (although my goal is to get them better) and so I did fill out their long term disability applications. I'm aware it's a disincentive to get better but the odds of them being well enough to work are super low anyway.

As a slight aside to all of this, I've come across physicians in other specialties who refuse to do any forms ("I don't do any paperwork" -- neuro, sleep, pain). Who is a patient supposed to ask if they're actually disabled by their epilepsy/narcolepsy/severe chronic pain other than the doctor who treats them for said issue?

 

[Sushirolls]

Third party doctors, not the treating doctors.

 

[Ironspy]

I’ll do short term disability if I think it’s appropriate which is honestly very rare. I’ve needed short term disability paperwork filled out to get paid for maternity leave with short term disability money and I’d have been pretty pissed if my OB had told me to get an independent opinion. Same goes for having surgery. It’s the treating surgeon who did the paperwork. It seems like we are applying a different standard to mental health compared to the rest of medicine here IMO.

Long term disability is a different beast and I don’t get involved in that.

 

[Sushirolls]

I’ll do short term disability if I think it’s appropriate which is honestly very rare. I’ve needed short term disability paperwork filled out to get paid for maternity leave with short term disability money and I’d have been pretty pissed if my OB had told me to get an independent opinion. Same goes for having surgery. It’s the treating surgeon who did the paperwork. It seems like we are applying a different standard to mental health compared to the rest of medicine here IMO.

Long term disability is a different beast and I don’t get involved in that.

We are applying different standards - they are different conditions.
Pregnancy is straightforward - you are pregnant.
C-section, straight forward x amount of time off

Depression and anxiety are treatable. ECT, IOP, PHP, TMS, etc.
Some people who are seeking disability have not actually engaged fully into the treatment process or are unwilling to and simply declare "I'm disabled, fill out my paperwork"

Is a gravid or post op c-section women ever not fully engaged in treatment?

 

[clausewitz2]

We are applying different standards - they are different conditions.
Pregnancy is straightforward - you are pregnant.
C-section, straight forward x amount of time off

Depression and anxiety are treatable. ECT, IOP, PHP, TMS, etc.
Some people who are seeking disability have not actually engaged fully into the treatment process or are unwilling to and simply declare "I'm disabled, fill out my paperwork"

Is a gravid or post op c-section women ever not fully engaged in treatment?

And how does one attend a PHP or get regular ECT without missing work, pray tell?

You forget that probably a majority of jobs in this country do not have anything like paid sick leave but do have "if you don't show up on Monday you're fired"

 

[Sushirolls]

Yes, fill out FMLA in order to get ECT or do PHP. That's different than STD.

 

[Armadillos]

Should probably read the AMA's Guides to Causation, and at least know that there are some professional guidelines indicating a treating provider should not be doing this.

Short term disability forms I have seen specifically are labeling “treating attending physician” statement or something similar.

Would be absurd not to allow treating providers to sign short term disability forms. Given the modern transition of most companies to rely on short term disability policies to replace extended sick leave, almost every single person who has a non-government job and delivers a baby or has surgery is going to have their surgeon/OBGYN sign off on minimum of 6 weeks short term disability.

 

[Ironspy]

Yes, fill out FMLA in order to get ECT or do PHP. That's different than STD.

FMLA is unpaid leave which guarantees that you cannot be fired for up to 12 weeks. Short term disability benefits allow you to get some money during FMLA leave-often a fraction of your normal salary.

 

[whopper]

If asked to do disability forms and I only see the patient in my office as a treating doctor I usually write a disclaimer stating that I only see the patient for 30 minute sessions and this type of evaluation will not meet the level of objectivity and scrutiny as a forensic evaluation by a non-treating evaluator. Due to these reasons I can only base my evaluation on what I see and hear during 30 minute evaluations that can greatly limit my ability to evaluate.

Also repeating what was written above, if someone asks me to do disability evaluations, I tend to write more favorably if the patient underwent more significant treatments. E.g. hardly any patient is going to malinger depression if they are willing to undergo ECT, if that person undergoes ECT, heck holy geez I'm more convinced this is a bona-fide real case.

I just had a patient who stopped seeing me who wanted me to do a disability evaluation and I point-blank told her that she's told me several times that the cause of her depression was her job and if she had a different job she'd likely not be depressed, and she refused my recommendations to undergo TMS telling me her depression was "situational" from the job. I told her that I'd be forced to write this down on her evaluation. I never saw her again. This was also a patient where I brought this issue up several times. "If you really are depressed why wouldn't you want to do TMS? "Because the depression is from my job. It's situational."

 

[Sushirolls]

FMLA is unpaid leave which guarantees that you cannot be fired for up to 12 weeks. Short term disability benefits allow you to get some money during FMLA leave-often a fraction of your normal salary.

I'm aware of these distinctions.
STD policies all vary. Some don't kick in until 4 or 6 or even 12 weeks after they filed. There are many nuances to FMLA / STD. Some STD policies require people have exhausted FMLA first.

In short, as #3 post describes, if time is spent off, people should be doing something to further their recovery.

 

[PsyDr]

Short term disability forms I have seen specifically are labeling “treating attending physician” statement or something similar.

Would be absurd not to allow treating providers to sign short term disability forms. Given the modern transition of most companies to rely on short term disability policies to replace extended sick leave, almost every single person who has a non-government job and delivers a baby or has surgery is going to have their surgeon/OBGYN sign off on minimum of 6 weeks short term disability.

I think it is absurd to allow some corporate policy to supersede professional guidelines.

 

[Armadillos]

I think it is absurd to allow some corporate policy to supersede professional guidelines.

In my experience the short term disability “treating physician” forms just are asking me to write down various facts summarizing medical record such as diagnosis, current/past symptoms, past treatments, my prognosis, expected recovery time, if I have advised them not to work, etc.

This then seems to be reviewed by someone from the company or independent consultant who makes a determination. Occasionally they call me and ask for clarification to help make their decision.

Ultimately I’m just providing information to a third party, so they can make a determination.

 

[PsyDr]

In my experience the short term disability “treating physician” forms just are asking me to write down various facts summarizing medical record such as diagnosis, current/past symptoms, past treatments, my prognosis, expected recovery time, if I have advised them not to work, etc.

This then seems to be reviewed by someone from the company or independent consultant who makes a determination. Occasionally they call me and ask for clarification to help make their decision.

Ultimately I’m just providing information to a third party, so they can make a determination.

Ultimately the AMA and the AAPLS have opined that treating providers should not become involved in legal matters, including disability. Dunno how you work around that.

What part of the tolerance section of the return to work guidelines do you use? Cause you read the professional guidelines in that area, before offering an opinion, right?

 

[Armadillos]

Ultimately the AMA and the AAPLS have opined that treating providers should not become involved in legal matters, including disability. Dunno how you work around that.

What part of the tolerance section of the return to work guidelines do you use? Cause you read the professional guidelines in that area, before offering an opinion, right?

I think your conflating what are actually genuine bona fide big legal questions (long term disability, fitness to serve in armed forces, competency for trial,etc) with other much more routine things that are just part of the routine practice of medicine in modern society.

I have no idea what specific guidelines your talking about and if you asked 100 OBGYNs/surgeons/family doctors none of them would either, but all of them on a daily basis provide clinical opinions on when they do or don’t recommended that someone work in the short term.

The medical system would completely break if treating doctors had to send patients to an independent (and expensive) evaluation every time a patient needed a sick day work excuse, return to work after illness/surgery/hospitalization form, short term disability form, etc.

And again, back to the relevant question of the the “treating physician” short term disability forms, we aren’t actually determining someone is disabled. Just providing the requested data for the disability company to pass along to whichever hired gun they contract out the determinations to.

Are you the same psychologist who was trolling the forum awhile ago about benzos for procedural sedation? As I typed this post felt some deja vu

 

[clausewitz2]

I think your conflating what are actually genuine bona fide big legal questions (long term disability, fitness to serve in armed forces, competency for trial,etc) with other much more routine things that are just part of the routine practice of medicine in modern society.

I have no idea what specific guidelines your talking about and if you asked 100 OBGYNs/surgeons/family doctors none of them would either, but all of them on a daily basis provide clinical opinions on when they do or don’t recommended that someone work in the short term.

The medical system would completely break if treating doctors had to send patients to an independent (and expensive) evaluation every time a patient needed a sick day work excuse, return to work after illness/surgery/hospitalization form, short term disability form, etc.

And again, back to the relevant question of the the “treating physician” short term disability forms, we aren’t actually determining someone is disabled. Just providing the requested data for the disability company to pass along to whichever hired gun they contract out the determinations to.

Are you the same psychologist who was trolling the forum awhile ago about benzos for procedural sedation? As I typed this post felt some deja vu

@PsyDr was indeed the person who implied it is illegal or fraudulent to give someone Ativan before a CT scan without a specific diagnosis to justify it. They are not someone who has a good grasp on how medicine is actually practiced.

At the end of the day, guidelines are great and all, but I am happy to say that in more than one area I do not infrequently find myself doing something not in relevant guidelines. I always make sure to have justification and be very cognizant of what I am doing but there it is.

Legal niceties are not the same as morality or clinical good judgment. Do you recognize the difference, @PsyDr ? I've never seen you draw the distinction.

 

[downwithDTB]

Ultimately the AMA and the AAPLS have opined that treating providers should not become involved in legal matters, including disability. Dunno how you work around that.

You work around it by ignoring it. The AMA in particular has no authority on anything. One of the editors of their "guide to causation" has Daniel Amen in his bio as a collaborator. My SPECT scan says that I don't care what he says. I only trust friends of Mehmet Oz.

I imagine that AAPLS has a position statement that forensic psychiatists must accept affordable payment for anyone who wants a short term disability eval. There is no way that a low SES person with a severe MDE needing partial and ECT is going to be able to get a second psychiatist to evaluate them in a timely fashion. I'm all for signing the forms in the extra rare case that it's needed and perfectly happy to be frank with my patients when it's not appropriate.

If you're a good phsyician who says no when things aren't indicated and refers when it's beyond your capacity, I can't find an arguement for why you shouldn't do it for your own patient. If you're afraid that you can't say no to a patient or would appease them inappropriately to keep them coming back... get a new job.

 

[PsyDr]

I think your conflating what are actually genuine bona fide big legal questions (long term disability, fitness to serve in armed forces, competency for trial,etc) with other much more routine things that are just part of the routine practice of medicine in modern society.

I have no idea what specific guidelines your talking about and if you asked 100 OBGYNs/surgeons/family doctors none of them would either, but all of them on a daily basis provide clinical opinions on when they do or don’t recommended that someone work in the short term.

The medical system would completely break if treating doctors had to send patients to an independent (and expensive) evaluation every time a patient needed a sick day work excuse, return to work after illness/surgery/hospitalization form, short term disability form, etc.

And again, back to the relevant question of the the “treating physician” short term disability forms, we aren’t actually determining someone is disabled. Just providing the requested data for the disability company to pass along to whichever hired gun they contract out the determinations to.

Are you the same psychologist who was trolling the forum awhile ago about benzos for procedural sedation? As I typed this post felt some deja vu

Im not trolling at all. I am a psychologist who deals with this stuff on a daily basis. And explaining this stuff probably harms my overall ear if potential.

There are professional standards. Many many many psychiatrists and psychologists seem to either be unaware or willfully ignorant of these standards. The entire idea of pragmatism trumping professional guidelines is not only lazy; it’s saying that the rules only apply when it’s convenient to you. Thankfully we know the personality configuration for that.

 

[PsyDr]

@PsyDr was indeed the person who implied it is illegal or fraudulent to give someone Ativan before a CT scan without a specific diagnosis to justify it. They are not someone who has a good grasp on how medicine is actually practiced.

At the end of the day, guidelines are great and all, but I am happy to say that in more than one area I do not infrequently find myself doing something not in relevant guidelines. I always make sure to have justification and be very cognizant of what I am doing but there it is.

Legal niceties are not the same as morality or clinical good judgment. Do you recognize the difference, @PsyDr ? I've never seen you draw the distinction.

I do not believe I said it was fraudulent or illegal to give a benzo for a procedure . I asked what the diagnosis was, and you guys responded with ad hominems. Which was cool.

 

[Armadillos]

Im not trolling at all. I am a psychologist who deals with this stuff on a daily basis. And explaining this stuff probably harms my overall ear if potential.

There are professional standards. Many many many psychiatrists and psychologists seem to either be unaware or willfully ignorant of these standards. The entire idea of pragmatism trumping professional guidelines is not only lazy; it’s saying that the rules only apply when it’s convenient to you. Thankfully we know the personality configuration for that.

We will have to agree to disagree, I have worked with reputable forensic psychiatrists and clinical psychologists who all would laugh their ass off if I referred a woman with postpartum depression to them so she get could get a “treating physician statement” form signed.

As “attending physician” who “treats” patients, I will be happy to defend any lawsuit I encounter for what you think is the wrong act of filling out a “treating attending physician statement” form mailed specifically to me by an insurance company at the request of a patient of mine.

 

[PsyDr]

We will have to agree to disagree, I have worked with reputable forensic psychiatrists and clinical psychologists who all would laugh their ass off if I referred a woman with postpartum depression to them so she get could get a “treating physician statement” form signed.

As “attending physician” who “treats” patients, I will be happy to defend any lawsuit I encounter for what you think is the wrong act of filling out a “treating attending physician statement” form mailed specifically to me by an insurance company at the request of a patient of mine.

I really don’t think there would be a lawsuit. And I don’t care what you do so long as what you do is completely informedwith a familiarity with your own professional guidelines. Give me a reasonable minority.

Imagine work where you read guidelines, and then say, “did you do these guidelines?”, and they freak out on you, tell you that the rules don’t apply to them, that they don’t even know what you’re taking about.

 

[clausewitz2]

I do not believe I said it was fraudulent or illegal to give a benzo for a procedure . I asked what the diagnosis was, and you guys responded with ad hominems. Which was cool.

No, we kept telling you that nobody documents a specific diagnostic code or diagnosis when doing this in any of the dozens of institutions we have collectively worked in and you kept asking what the code is. You also said you were a forensic psychologist several times and that you testify in court when we told you this isn't how it actually works and is not a thing that is done.

I see three possible things you were trying to say: a) you don't like to read what people are saying b) you like mentioning irrelevant things or c) there is something wrong with this practice relevant to you being a forensic psychologist.

No ad hominem here my friend.

 

[clausewitz2]

I really don’t think there would be a lawsuit. And I don’t care what you do so long as what you do is completely informedwith a familiarity with your own professional guidelines. Give me a reasonable minority.

Imagine work where you read guidelines, and then say, “did you do these guidelines?”, and they freak out on you, tell you that the rules don’t apply to them, that they don’t even know what you’re taking about.

Would you accept "every primary care doc in the country, give or take" as a reasonable minority?

 

[PsyDr]

No, we kept telling you that nobody documents a specific diagnostic code or diagnosis when doing this in any of the dozens of institutions we have collectively worked in and you kept asking what the code is. You also said you were a forensic psychologist several times and that you testify in court when we told you this isn't how it actually works and is not a thing that is done.

I see three possible things you were trying to say: a) you don't like to read what people are saying b) you like mentioning irrelevant things or c) there is something wrong with this practice relevant to you being a forensic psychologist.

No ad hominem here my friend.

I’m almost always being extremely literal and direct on sdn. And I’m trying to promote you guys to either:

1) use diagnostic criteria and the resulting treatment guidelines. You guys get mad af when I bring this up. Doesn’t change the matter.

2) change the professional guidelines for your own profession. I have zero influence in this, but just maybe if there are problems it should be handled.

3) learn your own professional guideline and give a reasonable explanation for the deviation thereof.

I refuse to believe that your profession refuses to read the literature and professional guidelines before engaging in a practice area. You’re better than that.

 

[clausewitz2]

I’m almost always being extremely literal and direct on sdn. And I’m trying to promote you guys to either:

1) use diagnostic criteria and the resulting treatment guidelines. You guys get mad af when I bring this up. Doesn’t change the matter.

2) change the professional guidelines for your own profession. I have zero influence in this, but just maybe if there are problems it should be handled.

3) learn your own professional guideline and give a reasonable explanation for the deviation thereof.

I refuse to believe that your profession refuses to read the literature and professional guidelines before engaging in a practice area. You’re better than that.

Please identify the actual, concrete, clinical problem caused by not making up a specific diagnosis before giving an empiric benzo to someone inpatient so they can get an MRI.

Please also identify the patients or providers who benefit from having a factitious and arbitrary code recorded consistently prior to receiving it.

 

[FlowRate]

I’m almost always being extremely literal and direct on sdn. And I’m trying to promote you guys to either:

1) use diagnostic criteria and the resulting treatment guidelines. You guys get mad af when I bring this up. Doesn’t change the matter.

2) change the professional guidelines for your own profession. I have zero influence in this, but just maybe if there are problems it should be handled.

3) learn your own professional guideline and give a reasonable explanation for the deviation thereof.

I refuse to believe that your profession refuses to read the literature and professional guidelines before engaging in a practice area. You’re better than that.

This is an essential difference between physicians (psychiatrists) and other MH disciplines (psychology, social work.) We grew up in the medical model where you have a lot of leeway to make decisions in the best interest of the patient. There is not a perfect evidence base for every possible combination of conditions. Sometimes you have to use your knowledge of pathology, drug mechanism, and, as psychiatrists, psychological and social factors, to arrive at a reasonable treatment plan. Guidelines are just that, suggested treatment plans not taking specific patient factors into account.

BTW, the AMA guides are controversial, not universally accepted guidelines, and most of the examples we're discussing are not related to cause determination.

 

[psyguru]

Aware of this but unfortunately encouraged by my attendings to do it anyway for patients who are deserving.

I have a couple of patients who I really don't think will ever be able to work (although my goal is to get them better) and so I did fill out their long term disability applications. I'm aware it's a disincentive to get better but the odds of them being well enough to work are super low anyway.

As a slight aside to all of this, I've come across physicians in other specialties who refuse to do any forms ("I don't do any paperwork" -- neuro, sleep, pain). Who is a patient supposed to ask if they're actually disabled by their epilepsy/narcolepsy/severe chronic pain other than the doctor who treats them for said issue?

A doctor that performs IMEs. I was recently retained by an attorney to do a guardianship form (which I have done as a clinician), for a patient who was hospitalized at a psychiatric hospital where the psychiatrist has a zero paperwork policy. This patient has a long history of psychosis and arrests and obviously needed a guardian. When you have unlimited funded time, you can do a very thorough job. I interviewed the examinee, hospital staff and both siblings of the patient along with reviewing medical records.

FYI this guardianship form specifically asked how long I have been treating this patient. So this form was intended on being completed by the clinical psychiatrist and not an independent forensic psychiatrist. I did acknowledge on this form I had no doctor/patient relationship with the examinee.

 

[PsyDr]

Please identify the actual, concrete, clinical problem caused by not making up a specific diagnosis before giving an empiric benzo to someone inpatient so they can get an MRI.

Please also identify the patients or providers who benefit from having a factitious and arbitrary code recorded consistently prior to receiving it.

1) Medications are created for specific purposes. If there is a specific pathology, then appropriate treatment is a nonissue. If there are no diagnoses, then where are the limit for medications used to ease nonpathological issues? It would seem that on the improving end, this is ethically discussed under the cognitive enhancement literature. It would seem that on the abusing end, this remains an open issue in such realms as harm reduction. If there are no limits on use of medications for nonpathological issues, then at what point is the insurer or other paying third party responsible?

2) I am not advocating factitious diagnoses at all. I would presume that a patient's insurance requires a diagnosis for a medication.

This is an essential difference between physicians (psychiatrists) and other MH disciplines (psychology, social work.) We grew up in the medical model where you have a lot of leeway to make decisions in the best interest of the patient. There is not a perfect evidence base for every possible combination of conditions. Sometimes you have to use your knowledge of pathology, drug mechanism, and, as psychiatrists, psychological and social factors, to arrive at a reasonable treatment plan. Guidelines are just that, suggested treatment plans not taking specific patient factors into account.

BTW, the AMA guides are controversial, not universally accepted guidelines, and most of the examples we're discussing are not related to cause determination.

I'm fine with an informed and reasoned opinion, but part of that approach is referencing that such guidelines exist.

 

[VA Hopeful Dr]

2) I am not advocating factitious diagnoses at all. I would presume that a patient's insurance requires a diagnosis for a medication.

You presume wrong

 

[downwithDTB]

1) Medications are created for specific purposes. If there is a specific pathology, then appropriate treatment is a nonissue.

I assume that you are equally against the use of psychotherapeutic techniques to treat non-pathology and clearly label every technique that you employ in every session and exactly what pathology it is addressing in a purely evidence based fashion, meaning that if there is no adequately blinded and controlled experiment of your intervention for a population with the exact comborbidity of your patient you do nothing.

You're also, I assume, adamently against ever having a beer to feel a little better or coffee in the AM when you're tired. Part of being physician is knowing when pharmacology can very judiciously be used without harm to improve life in a way that doesn't grant a competitive advantage/come with significant risks. Should we not treat pain, a completely normal phsyiological response?

 

[PsyDr]

I assume that you are equally against the use of psychotherapeutic techniques to treat non-pathology and clearly label every technique that you employ in every session and exactly what pathology it is addressing in a purely evidence based fashion, meaning that if there is no adequately blinded and controlled experiment of your intervention for a population with the exact comborbidity of your patient you do nothing.

You're also, I assume, adamently against ever having a beer to feel a little better or coffee in the AM when you're tired. Part of being physician is knowing when pharmacology can very judiciously be used without harm to improve life in a way that doesn't grant a competitive advantage/come with significant risks. Should we not treat pain, a completely normal phsyiological response?

1) I am against the us of evidence based techniques for non-pathologies. My notes are extremely detailed. When I deviate from the evidence base or practice guidelines, I acknowledge that these things exist and that I am departing from them for a specific reason. In my understanding, this is part of avoiding the negligence arm of a malpractice tort.

b. You are onto something. I do conceptualize psychotherapy as having two uses: treating pathology, and for self knowledge/improvement. I do not believe that third party payors should pay for the latter.

2) One of my approaches to understanding something is to think about the limits of things. Personal choices might be a bad analog, given the lack of a prescriber and third party payor. Pain is an interesting analog. Are there guidelines about the lower limits of pain to initiate treatment?

 

[clausewitz2]

1) Medications are created for specific purposes.

As a factual claim about the history of how pharmaceutical agents are developed, this is breathtakingly ill-informed. I can only assume you would say this from being genuinely unfamiliar with the facts of the matter, which is fine given you don't prescribe medications. Now if only you stopped making claims about how they are prescribed...

There is an entire specialty dedicated to symptomatic treatment without any attempt or interest in correcting a putative underlying pathology, namely palliative care. I would love to hear you explain how they are all being grossly negligent because they are harnessing non-specific effects of medications to make patients' lives more bearable or to die well.

You keep using the word "pathology" like it has an independent meaning or is an easily read-off property of the world. This is just not the case in the majority of chronic medical illnesses, and in mental health all it means is "thing a committee of people decided to call pathology". The distinction between pathological and non is much more notional than actual.

I would love to see an example of a malpractice suit being won by a plaintiff on the basis of a medication being used in a non-specific fashion to achieve a well- documented effect. If not, well...

 

[whopper]

Penicillin's discovery of it's antibiotic properties were accidental.

Several meds are found to have benefits no one knew about until later on. E.g. Aspirin's anti-inflammatory benefits, low-dosage Naltrexone is found to be a potent anti-inflammatory and reduces pain in Fibromyalgia, several atypical antipsychotics were found to have antidepressant augmentation benefits.

There are literally thousands of cataloged chemicals in the blood and we have no idea what their purpose is if anything. There are dozens of chemicals in the brain and we have no idea what their purpose is and what effects will happen if they are manipulated.

 

[downwithDTB]

B. You are onto something. I do conceptualize psychotherapy as having two uses: treating pathology, and for self knowledge/improvement. I do not believe that third party payors should pay for the latter.

You are now a third party payor, congratulations. I have a patient who is a bit anxious about getting their brain MRI. I do not have evidence of a specific phobia or any other diagnosis. They think that a little something to help them calm down would be nice.

You have two choices: you can trust my judgement and pay $0.50 for an Ativan or you can risk the procedure happening without the Ativan and in my experience you're risking about a 50/50 having to repeat a $1000 scan. Now you can make me code this excessively and make up some diagnosis, ect., but I'm going to drop you as a payor because frankly that's a waste of my time and now you don't have any hospitals that take your plan and all of your customers drop you.

That's the world that I live in.

 

[WisNeuro]

You are now a third party payor, congratulations. I have a patient who is a bit anxious about getting their brain MRI. I do not have evidence of a specific phobia or any other diagnosis. They think that a little something to help them calm down would be nice.

You have two choices: you can trust my judgement and pay $0.50 for an Ativan or you can risk the procedure happening without the Ativan and in my experience you're risking about a 50/50 having to repeat a $1000 scan. Now you can make me code this excessively and make up some diagnosis, ect., but I'm going to drop you as a payor because frankly that's a waste of my time and now you don't have any hospitals that take your plan and all of your customers drop you.

That's the world that I live in.

Not quite the world we live in. To be honest, being a ****ty third party payor that refuses to cover a lot of things has not caused many people to do much about it. Just ask United and BCBS, particularly in my region. People (providers and patients alike) absolutely hate them. Doesn't stop them from reaping record profits. Insurance and healthcare don't really operate on the ideals of the free market.

 

[clausewitz2]

Not quite the world we live in. To be honest, being a ****ty third party payor that refuses to cover a lot of things has not caused many people to do much about it. Just ask United and BCBS, particularly in my region. People (providers and patients alike) absolutely hate them. Doesn't stop them from reaping record profits. Insurance and healthcare don't really operate on the ideals of the free market.

That's all true enough, but you know what I have never seen even cut rate insurance refuse to pay for?

Half a milligram of Ativan for someone who needs an MRI and has no anxiety diagnosis.

Just. Not. A. Thing. I am not sure why this statement is controversial.

 

[WisNeuro]

That's all true enough, but you know what I have never seen even cut rate insurance refuse to pay for?

Half a milligram of Ativan for someone who needs an MRI and has no anxiety diagnosis.

Just. Not. A. Thing. I am not sure why this statement is controversial.

Oh, I wasn't commenting on that, I'll let you guys fight that one out, it's fun to watch. I was merely commenting on the laughable idea that insurance companies are subject to any kind of market pressure for not paying for things, or being generally terrible entities for anyone involved to have to deal with.

 

[Mass Effect]

Ultimately the AMA and the AAPLS have opined that treating providers should not become involved in legal matters, including disability. Dunno how you work around that.

What part of the tolerance section of the return to work guidelines do you use? Cause you read the professional guidelines in that area, before offering an opinion, right?

Until the AMA shows some teeth on other issues, I think I'll continue to abide by my personal ethics and what I think is right for my patient.

 

[downwithDTB]

Oh, I wasn't commenting on that, I'll let you guys fight that one out, it's fun to watch. I was merely commenting on the laughable idea that insurance companies are subject to any kind of market pressure for not paying for things, or being generally terrible entities for anyone involved to have to deal with.

Fine, that was a little extreme, but I submit the main point that insurance companies would take paying for Ativan before an MRI any day over the risk of paying for two mris.

 

[Mass Effect]

3) learn your own professional guideline and give a reasonable explanation for the deviation thereof.

The form says "treating physician" and I am signing my name to a document in which I am swearing that I am the treating physician. Because I am the treating physician.

 

[PsyDr]

As a factual claim about the history of how pharmaceutical agents are developed, this is breathtakingly ill-informed. I can only assume you would say this from being genuinely unfamiliar with the facts of the matter, which is fine given you don't prescribe medications. Now if only you stopped making claims about how they are prescribed...

There is an entire specialty dedicated to symptomatic treatment without any attempt or interest in correcting a putative underlying pathology, namely palliative care. I would love to hear you explain how they are all being grossly negligent because they are harnessing non-specific effects of medications to make patients' lives more bearable or to die well.

You keep using the word "pathology" like it has an independent meaning or is an easily read-off property of the world. This is just not the case in the majority of chronic medical illnesses, and in mental health all it means is "thing a committee of people decided to call pathology". The distinction between pathological and non is much more notional than actual.

I would love to see an example of a malpractice suit being won by a plaintiff on the basis of a medication being used in a non-specific fashion to achieve a well- documented effect. If not, well...

That's a lot of inferences about things I never said.

At no point did I say there was a malpractice suit. I was asked what I did, I explained, and included my own rationale.

And let's keep in mind, you guys brought up the entire benzos thing AGAIN. Not me. And it was brought up as an ad hominem.

 

[clausewitz2]

That's a lot of inferences about things I never said.

At no point did I say there was a malpractice suit. I was asked what I did, I explained, and included my own rationale.

And let's keep in mind, you guys brought up the entire benzos thing AGAIN. Not me. And it was brought up as an ad hominem.

Ah yes, you only use direct and literal language and never try to imply anything beyond the concrete referents of your words. Right, so this sentence of yours from up-thread about why everything must be documented as targeting specific pathology:

"In my understanding, this is part of avoiding the negligence arm of a malpractice tort."

I will assume this is meant to be a sentence of American English rather than a Martian dialect that you can construct a false cognate sentence matching this one in as a party trick. So, praytell, being very literal and direct, explain again how you did not mention a malpractice suit related to this issue?

Let's be clear, though. You can't talk about what you do in prescribing medications because you don't (unless they are tapping prescribing psychologists to staff MRI suites, bit of a waste). So you are either analogizing (non-literal) or being irrelevant (useless).

You are trying to have it both ways - you make statements insisting that universal practices are wrong for very unconvincing reasons, and then when you get pushback on those reasons you start saying that you never said any such thing.

For someone proud of careful language use it is surprising how unaware you are of how native English speakers interpret sentences. Assuming you are arguing in good faith, of course, which I dearly still want to believe.

 

[PsyDr]

Ah yes, you only use direct and literal language and never try to imply anything beyond the concrete referents of your words. Right, so this sentence of yours from up-thread about why everything must be documented as targeting specific pathology:

"In my understanding, this is part of avoiding the negligence arm of a malpractice tort."

I will assume this is meant to be a sentence of American English rather than a Martian dialect that you can construct a false cognate sentence matching this one in as a party trick. So, praytell, being very literal and direct, explain again how you did not mention a malpractice suit related to this issue?

Let's be clear, though. You can't talk about what you do in prescribing medications because you don't (unless they are tapping prescribing psychologists to staff MRI suites, bit of a waste). So you are either analogizing (non-literal) or being irrelevant (useless).

You are trying to have it both ways - you make statements insisting that universal practices are wrong for very unconvincing reasons, and then when you get pushback on those reasons you start saying that you never said any such thing.

For someone proud of careful language use it is surprising how unaware you are of how native English speakers interpret sentences. Assuming you are arguing in good faith, of course, which I dearly still want to believe.

You're taking that quote out of context. That specific quote is my response to someone asking about my own practices. Which I gave, and gave my rationale for. At no point did I say anything about someone being liable for malpractice. That is your assumption.

I did NOT bring up the benzos discussion. You guys did. To my knowledge, I haven't said that was wrong. I asked what the diagnosis was. And absent diagnoses, I have asked what the limits are.

My specific thing in this thread was asking about psychiatry's professional standards and the limits thereof.

 

[clausewitz2]

You're taking that quote out of context. That specific quote is my response to someone asking about my own practices. Which I gave, and gave my rationale for. At no point did I say anything about someone being liable for malpractice. That is your assumption.

I did NOT bring up the benzos discussion. You guys did. To my knowledge, I haven't said that was wrong. I asked what the diagnosis was. And absent diagnoses, I have asked what the limits are.

My specific thing in this thread was asking about psychiatry's professional standards and the limits thereof.

Really? So what's the question, exactly?

The Ativan thing came up because it is much of a muchness with your beef about short term disability. The form goes like this:

1) you post here, citing a professional society guideline or legal or insurance standard as a reason for saying that an incredibly common and unremarkable practice that you don't participate in is wrong.

2) you mention that you are forensically trained and that malpractice is a thing without explicitly ever connecting it to #1, funny how that keeps happening

3) we say "this is actually super common and uncontroversial in practice"

4) you continue saying a combination of 1+3

5) we challenge your assumptions (unstated but based on repeated references to legal standards) that this puts us in medicolegal jeopardy

6) we tell you that is ridiculous

7) you maintain you are just asking questions, jeez, why are you all so mad, you never said anything about a lawsuit, calm down

I just ask that you take a moment to consider the possibility that people who do this every day for their job are maybe slightly more familiar with how things actually work and what a sensible set of guidelines should be based on than you do, who does not practice medicine, as it happens.

 

[michaelrack]

F40.232

 

[PsyDr]

Really? So what's the question, exactly?

The Ativan thing came up because it is much of a muchness with your beef about short term disability. The form goes like this:

1) you post here, citing a professional society guideline or legal or insurance standard as a reason for saying that an incredibly common and unremarkable practice that you don't participate in is wrong.

2) you mention that you are forensically trained and that malpractice is a thing without explicitly ever connecting it to #1, funny how that keeps happening

3) we say "this is actually super common and uncontroversial in practice"

4) you continue saying a combination of 1+3

5) we challenge your assumptions (unstated but based on repeated references to legal standards) that this puts us in medicolegal jeopardy

6) we tell you that is ridiculous

7) you maintain you are just asking questions, jeez, why are you all so mad, you never said anything about a lawsuit, calm down

I just ask that you take a moment to consider the possibility that people who do this every day for their job are maybe slightly more familiar with how things actually work and what a sensible set of guidelines should be based on than you do, who does not practice medicine, as it happens.

There are exactly 3 items out of 7 that’s mine.
You seem pretty worked up on that.

I’ll reply that someone who does this every day for his job might have a reasonable set of questions.

Edit: or maybe those appeals to authority are formal errors of logic.

 

[clausewitz2]

There are exactly 3 items out of 7 that’s mine.
You seem pretty worked up on that.

I’ll reply that someone who does this every day for his job might have a reasonable set of questions.

Edit: or maybe those appeals to authority are formal errors of logic.

And yet you can't except reasonable, factual answers. What would satisfy you, exactly?

Formal logic is a truth-preserving mechanism, nothing more. If the premises are flawed, and they are, deductive logic does not lead to true conclusions.

It is not an appeal to authority to say that the experience of practitioners is dispositive of whether a practice is typical of practitioners or typical of normal practice.