Work restrictions and disability

[Timeoutofmind]

I get pts coming in asking for work restrictions...moderate changes on lumbar MRI. Nonfocal neuro exam. Just telling me it is too painful. Asking for light duty, 10# limit or whatever. How am I supposed to know how true that is and even what restrictions are reasonable?
Sometimes orthos will even write a letter with restrictions and write in the letter that all further restrictions will come from me. Or an employer will say they want a letter from me agreeing with the PCPs restriction letter.
Also people wanting disability in similar circumstances.

Pcps pissed if I punt.

How do u guys handle this? So overwhelming and discouraging for a new grad. I don't want anything to do with all this crap, and feel I am not trained or adept to even make these decisions.

I told a couple people so far they could do an FCE and I would write whatever restrictions in accordance with this...but I know these are not perfect tests either?

Thanks in advance, struggling here. I wanna do what's right, but really feel like the pts and other Drs are just crapping all over me with this...I don't want to contribute to the rampant disability abuse, but possibly some of these people have major pain with their factory type lifting jobs?

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[101N]

Can recommend a formal FCE?

 

[DrCommonSense]

I get pts coming in asking for work restrictions...moderate changes on lumbar MRI. Nonfocal neuro exam. Just telling me it is too painful. Asking for light duty, 10# limit or whatever. How am I supposed to know how true that is and even what restrictions are reasonable?
Sometimes orthos will even write a letter with restrictions and write in the letter that all further restrictions will come from me. Or an employer will say they want a letter from me agreeing with the PCPs restriction letter.
Also people wanting disability in similar circumstances.

Pcps pissed if I punt.

How do u guys handle this? So overwhelming and discouraging for a new grad. I don't want anything to do with all this crap, and feel I am not trained or adept to even make these decisions.

I told a couple people so far they could do an FCE and I would write whatever restrictions in accordance with this...but I know these are not perfect tests either?

Thanks in advance, struggling here. I wanna do what's right, but really feel like the pts and other Drs are just crapping all over me with this...I don't want to contribute to the rampant disability abuse, but possibly some of these people have major pain with their factory type lifting jobs?

FCE is the method of handling this where the patient pays out of pocket

 

[nvrsumr]

I say u need special kind of doc called an occupational medicine doc and leave it as that. I do not even write for handicap parking placards

 

[Timeoutofmind]

FCE is the method of handling this where the patient pays out of pocket

My understanding is that while an FCE has some internal controls for faking, a lot of people still BS their way thru it and get a false assessment?

 

[Timeoutofmind]

I say u need special kind of doc called an occupational medicine doc and leave it as that. I do not even write for handicap parking placards

My occ med colleague is not cool with such consults.
If it's workmans comp, that's ok as far as determining status. But if they were not hurt on the job, he doesn't want it...is this unusual?

 

[DrCommonSense]

My understanding is that while an FCE has some internal controls for faking, a lot of people still BS their way thru it and get a false assessment?

A good fce will basically write they are attempting to underperform on the test. Have seen plenty of those. I use fce person that will write that stuff mostly on tests. Never wrote full disability only restrictions for people after fce.

Also, they will get social security disability for literally anything so even if you write the person can work, the govt will still place them on disability.

 

[lobelsteve]

My occ med colleague is not cool with such consults.
If it's workmans comp, that's ok as far as determining status. But if they were not hurt on the job, he doesn't want it...is this unusual?

Yup, it is his education, experience, and training. Also, PMR does this.

 

[Arantius]

Saw a lot of this on my pain rotation and I thought a good approach was allowing restrictions as long as the patient has functional ROM and strength exercises documented by physical therapy. They had to have an initial visit with PT and bring those records to fill out the light duty form (for short periods of time). Then, if they missed physical therapy appointments or were non-compliant they didn't get any more light duty. BUT a PCP can do this easily. Doesn't require a fellowship...

 

[NJPAIN]

I have struggled with this as well. Don't have a perfect solution. I find what does help is to at the beginning ( first visit )explain that in the workers comp world there are differences between restrictions, limitations and work problems. You can only place restrictions if an activity puts patient or the public at risk for HARM. If the activity does not place at risk for harm but causes pain you can say that there are no restrictions but that the patient reports symptoms that present a "work problem" and based upon that he chooses not to do the activity. One source advised that you may also comment on if the reported symptoms are believable based upon the known pathology. For what it's worth


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[Aether2000]

I used to believe in FCE but recently requested one on a patient and it lasted less than 1 hour. This is in comparison to the 14 hour FCEs spread over 2 days I used to see. Is it possible to follow the standard FCE protocol by those trained in FCE and complete it in under an hour?

 

[lobelsteve]

I used to believe in FCE but recently requested one on a patient and it lasted less than 1 hour. This is in comparison to the 14 hour FCEs spread over 2 days I used to see. Is it possible to follow the standard FCE protocol by those trained in FCE and complete it in under an hour?

There are many different FCE programs and the shady folks who work directly for the attorney often use no program, just basically talk to patient and watch them walk then generate a report.

I like :
Blankenship FCE: http://www.theblankenshipcenter.com/fce-ppd_center_002.htm
Matheson. https://www.roymatheson.com/about/matheson-fce-faqs


YMMV: https://www.occupro.net/docs/defaul...luations-must-be-evidence-based-and-valid.pdf

 

[Yo GabbaPentin]

I have struggled with this as well. Don't have a perfect solution. I find what does help is to at the beginning ( first visit )explain that in the workers comp world there are differences between restrictions, limitations and work problems. You can only place restrictions if an activity puts patient or the public at risk for HARM. If the activity does not place at risk for harm but causes pain you can say that there are no restrictions but that the patient reports symptoms that present a "work problem" and based upon that he chooses not to do the activity. One source advised that you may also comment on if the reported symptoms are believable based upon the known pathology. For what it's worth


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Does that work?? I'm already seeing a blank 1000 yard stare looking back at me after explaining that. Of course followed by the identical repeat request for a 4 month work excuse. That's after they are done reiterating their story of everything that they just can't do.

 

[Ducttape]

how about wording it this way: "im writing this prescription for pain medication to take after your shift is over. if you stop working, I stop writing."

 

[NJPAIN]

Does that work?? I'm already seeing a blank 1000 yard stare looking back at me after explaining that. Of course followed by the identical repeat request for a 4 month work excuse. That's after they are done reiterating their story of everything that they just can't do.

I'm often surprised when it does. I try to explain that WC has guidelines and laws that we have to work within. "It's not simply that you say it hurts when you work and I say you don't have to work until it doesn't hurt anymore and they need to pay you. If there is no significant risk of harm involved I cannot place a restriction. YOU can however say that you cannot work under those circumstances and then it is up to you and your attorney to deal with that". It's the I would love to help you but my hands are tied approach. Doesn't work every time. You can always take the spine surgeon's approach. That is, everyone is out of work for months and months until they have surgery. Then 3 months post surgery, without any improvement and without any PT (because they don't believe in PT) they are released to full duty.

 

[SSdoc33]

i cant get FCEs paid for. i stopped recommending them.

a patient comes in with an injury -- work related or not, put them on some form light duty. even if its sedentary work. patients may not like it, but they can do office work if their back hurts. if there is not a light duty position available at their work, that his the employer;s problem, not yours. give restrictions with your best guess. there are no formal guidelines to how much somebody can lift/push/pull. although employers want you to fill out their little worksheet with checklists, etc, you dont have to. they can ready your note like everybody else.

its such a dog and pony show. a patient comes in with an injury that may or may not be real. many of them dont want to get better. you prescribe treatments that are denied, and when they arent denied, they dont work because the patients dont want them to. gotta love it.

 

[DrCommonSense]

i cant get FCEs paid for. i stopped recommending them.

a patient comes in with an injury -- work related or not, put them on some form light duty. even if its sedentary work. patients may not like it, but they can do office work if their back hurts. if there is not a light duty position available at their work, that his the employer;s problem, not yours. give restrictions with your best guess. there are no formal guidelines to how much somebody can lift/push/pull. although employers want you to fill out their little worksheet with checklists, etc, you dont have to. they can ready your note like everybody else.

its such a dog and pony show. a patient comes in with an injury that may or may not be real. many of them dont want to get better. you prescribe treatments that are denied, and when they arent denied, they dont work because the patients dont want them to. gotta love it.

The patient can put out the 500 dollars needed for it. Thats the beauty of it.

 

[ampaphb]

The same way there are legit and fake and bake PTs, there are legit and BS FCEs. Figure out where in your area they are legit, and then, rather than referring for a generic FCE, refer to a specific, legitimate provider.

 

[NJPAIN]

It is a total dog and pony show. Much if not all of what they ask on those stupid forms are "medically unanswerable questions".


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[geauxg8rs]

It is a total dog and pony show. Much if not all of what they ask on those stupid forms are "medically unanswerable questions".


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What do you mean "medically unanswerable?"

Like my favorite question--

How many times over the next 12
Months will employee need to miss work for condition? And is it medically necessary?

The only answer I can put down--
I cannot portend the future.

Then they come back telling me I filled the form out wrong!

 

[SSdoc33]

i swear i write "unknown" half the time.

 

[ampaphb]

TBD.

 

[Ferrismonk]

Small bump for this thread. I'm a new grad and do basically the same thing. You want disability or a permanent handicap sticker? Get a formal FCE. I'll give you a temporary placard for a month or two to have the test done, that's it. So far, nobody has completed the exam. In my (albeit callous) opinion, if you can't do your job, get a different job.

Usually what happens, however, is they convince their PCP to write for disability or they somehow "get lost to followup" once they find someone who'll take over their meds.

 

[hyperalgesia]

I tell pts that pain itself is not a disability. If their orthopedic surgeon tells them they can't bear weight, that's another story.

I tell pts my goal is improved function. I want them to walk so why would I want them to park in a handicap zone?

 

[willabeast]

i wrote lots of work restrictions but never took anyone off work unless it was the day after a procedure.
even quadraplegics work (one of my favorite lines). OTOH i gave out plenty of handicapped parking passes. none of them are lifetime in California - they all have to be renewed. BTW i recently saw a totally jacked up truck (the stepping board was about my chest height) in a handicapped parking spot with a handicapped tag on it. i wish i had had my phone with me i would have taken a pic. hysterically funny.