What to do?

[randomdoc1]

I haven't had to deal with this in private practice before. But I started seeing someone for PTSD, she was on FMLA for about 6 weeks at that time. After a couple visits, she is now asking me to provide her documentation for longterm disability. Thing is, she has a history of being very resilient, has worked for most of her adult years, and has a history of being high functioning. The disability paperwork she gave me asks specifically if she meets our state's definition for being disabled longterm and it means her not being able to sustain gainful employment in any kind of job for the rest of her life. I do not think that is the case. It turns out the PCP responded affirmatively on this, but her disability needs two physicians to sign off. The patient later admits to me she did not even bother to look into other job options or even the fact that she can work for herself or free lance. I have reached out to the PCP twice to get their documentation but no response. In some ways, I felt like she was trying to pull a fast one on me. If it wasn't for the disability part, I don't think she would have sought a psychiatrist and I don't feel comfortable signing off on something like this. Her paperwork is also requiring me to complete documentation monthly attesting that she is unable to work. My practice has gotten so busy lately that this is just a lot of extra work for me as well. I'm seeing many patients and often have over 10 phone calls and PAs at the end of the day.

What would any of you do in this situation? Are there third parties she can go to, to be evaluated for longterm disability? What about transferring her to another psychiatrist (many of the private clinics do not have very long wait times) and recommending she be up front with the next provider? Thanks!

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[justfolks]

Just a patient, but sounds like the right answer here is "no, I'm sorry, I can't do that because I do not believe that you meet the applicable criteria."

 

[TexasPhysician]

Just refuse. Patient hasn’t given you adequate time to help her improve. Without sustained failure to improve and severe symptoms, she isn’t disabled long-term.

 

[birchswing]

I'm heartened that you care enough to ask, but I'm surprised that you care so much.

My psychiatrist a couple years ago adopted a new policy of not filling out or signing any forms for any reason: full stop. Prior that she charged what I thought were high prices just to sign a form that she would require the patient to fill out to the maximum extent possible beforehand and she would then give her signature. And my form was just to let my college know I had a medical condition that was treating me for and that I was attending sessions with her (because I was re-admitted after a medical leave). So my PCP had to do it instead, which was really odd because the form was to say that I was seeing the psychiatrist--not a PCP. So he instead had to testify that I was seeing my psychiatrist and what my condition and medications were, etc., even though I was self-reporting all that to him. So my college's assurance that I was seeing my psychiatrist was from my PCP's assurance which came from my assurance to him. If you look up Google Reviews of my psychiatrist a good chunk of them are complaints from college students for the same reason (I live in a college town).

All that is to say, it's nice you care so much as I don't think most people would give a second thought about not signing a form they don't agree is accurate let alone signing one they do think is accurate . . . unless they're really nice like my PCP, who is kind of rare.

 

[Attending1985]

I was trying to find this on an old thread but I couldn’t. It was saying that recommendations like this should not come from the treating psychiatrist but an independent examiner and you should decline to do it.

 

[erg923]

I haven't had to deal with this in private practice before. But I started seeing someone for PTSD, she was on FMLA for about 6 weeks at that time. After a couple visits, she is now asking me to provide her documentation for longterm disability. Thing is, she has a history of being very resilient, has worked for most of her adult years, and has a history of being high functioning. The disability paperwork she gave me asks specifically if she meets our state's definition for being disabled longterm and it means her not being able to sustain gainful employment in any kind of job for the rest of her life. I do not think that is the case. It turns out the PCP responded affirmatively on this, but her disability needs two physicians to sign off. The patient later admits to me she did not even bother to look into other job options or even the fact that she can work for herself or free lance. I have reached out to the PCP twice to get their documentation but no response. In some ways, I felt like she was trying to pull a fast one on me. If it wasn't for the disability part, I don't think she would have sought a psychiatrist and I don't feel comfortable signing off on something like this. Her paperwork is also requiring me to complete documentation monthly attesting that she is unable to work. My practice has gotten so busy lately that this is just a lot of extra work for me as well. I'm seeing many patients and often have over 10 phone calls and PAs at the end of the day.

What would any of you do in this situation? Are there third parties she can go to, to be evaluated for longterm disability? What about transferring her to another psychiatrist (many of the private clinics do not have very long wait times) and recommending she be up front with the next provider? Thanks!

IME

 

[randomdoc1]

I was trying to find this on an old thread but I couldn’t. It was saying that recommendations like this should not come from the treating psychiatrist but an independent examiner and you should decline to do it.

Great idea! This is what I found. I'll go ahead and discuss this with the patient then.

Page 486 in the AMA's Causation specifically states that the AMA, American Psychiatric Association, and the American Psychological Association have indicated that treating professionals should refrain from addressing forensic issues including disability and causation.

 

[thoffen]

I was trying to find this on an old thread but I couldn’t. It was saying that recommendations like this should not come from the treating psychiatrist but an independent examiner and you should decline to do it.

Basically this, although I would also tell her my concerns about meeting that criteria even with independent evaluation.

 

[PsyDr]

Basically this, although I would also tell her my concerns about meeting that criteria even with independent evaluation.

When I have a clinical case who suddenly brings a disability form, I explain that disability is a really specific thing which seems easy but is really not. Because I am obligated for their best interests by our clinical relationship, my opinion is considered biased by disability insurance. I also explain that filing in such a form could make their medical insurance reject payment, which they would be obligated to pay and I don’t want that hassle for either of us. I tell them that their disability insurer, even if it is ssdi, is required to provide an independent exam and the disability company is probably trying to cheap out on their claim, which is less than they deserve.

I have only agreed to fill out forms for 2 clinical patients, ever. Both had conditions with a life expectancy of less than 24 months.

 

[wolfvgang22]

In the VA I am pressured to fill out forms for every veteran who asks. So what I do is take an appointment to discuss it with the patient and fill it out right in front of him in the spirit of collaboration. I say I must be honest no matter what and write down the truth. If it isn't going to help the patient or result in a denial, I tell the patient and let them decide whether they will turn in the forms or not. I never give any forms to anybody but the patient. They usually end up not submitting the form after all unless they truly are disabled.

 

[Mass Effect]

When I have a clinical case who suddenly brings a disability form, I explain that disability is a really specific thing which seems easy but is really not. Because I am obligated for their best interests by our clinical relationship, my opinion is considered biased by disability insurance. I also explain that filing in such a form could make their medical insurance reject payment, which they would be obligated to pay and I don’t want that hassle for either of us. I tell them that their disability insurer, even if it is ssdi, is required to provide an independent exam and the disability company is probably trying to cheap out on their claim, which is less than they deserve.

I have only agreed to fill out forms for 2 clinical patients, ever. Both had conditions with a life expectancy of less than 24 months.

This is all new to me. In residency, we are expected to fill out these forms. So if a patient comes in with these forms, who do we tell them to contact for independent evaluation?

 

[TexasPhysician]

This is all new to me. In residency, we are expected to fill out these forms. So if a patient comes in with these forms, who do we tell them to contact for independent evaluation?

Interesting. In residency, we were forbidden from filling them all. All initiated an IME referral.

 

[thoffen]

I think there are some situations where you might choose to do it if in the interest of a patient and independent examination is a barrier, e.g. in a case of schizophrenia with limited insight and repeated hospitalizations which might be avoided without the added burden of homelessness, inability to afford the cost of treatment that is efficacious, lack of social support to assist in the effort, etc. Certainly there is a conflict of interest between treatment and disability evaluation, particularly if you have a role in continually evaluating appropriateness for the disability, but sometimes the most important interventions for a patient are not within your preferred role but within the scope of medical practice and you are the best or only likely person to get the intervention to happen. Even if someone has access to resources elsewhere, the difficulty establishing a productive relationship with those resources ought to be considered. This is, if course, an unlikely calculus when a person brings the disability forms to you.

 

[erg923]

This is all new to me. In residency, we are expected to fill out these forms. So if a patient comes in with these forms, who do we tell them to contact for independent evaluation?

The person who gave them/directed them to the f0rm.

 

[PsyDr]

This is all new to me. In residency, we are expected to fill out these forms. So if a patient comes in with these forms, who do we tell them to contact for independent evaluation?

I would quote the relevant ethical guidelines and refer them back to their disability insurer.

How one rectifies professional ethics and guidelines when it conflicts with their residency requirements is beyond me.