Work leave requests / disability forms

[SteinUmStein]

Good afternoon colleagues.

I've seen a fair number of patients over the past year (mostly outpatient) who request time off work, short term disability, and sometimes long-term disability. Just wondering what your approach tends to be in these situations, in what situations you refer for outside evaluation (forensic or otherwise), and when (if ever) you as the treating provider assist with long-term disability applications (such as completing LTD insurance forms, writing a disability or functional work assessment, etc). Does this come up regularly in other settings? It seems pretty common in our academic clinics. This is coming from the perspective of a non-forensic trained individual.

This question pertains to established patients who the treating provider knows, not necessarily consultations or initial evals.

Thanks in advance for your input.

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[PsyDr]

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.

 

[Shikima]

Very interesting when corporations are directing people to seek out a psychiatrist directly for being on sick leave which residency training isn't covering.

We need an occupational psychiatry sub specialty.

 

[wolfvgang22]

Residency definitely should cover this topic better. I know mine didn't address it except to say " we don't do that" most of the time. It was pretty much left up to my discretion most of the time, still is.

 

[F0nzie]

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.

I prefer to refer these out to protect the therapeutic alliance. When it's my patient and the disability is obvious I will do the eval. In a community setting, however, there is rarely anybody to refer out to. The problem is it's hard to find anybody that does these, even in a private setting.


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[erg923]

Good afternoon colleagues.

I've seen a fair number of patients over the past year (mostly outpatient) who request time off work, short term disability, and sometimes long-term disability. Just wondering what your approach tends to be in these situations, in what situations you refer for outside evaluation (forensic or otherwise), and when (if ever) you as the treating provider assist with long-term disability applications (such as completing LTD insurance forms, writing a disability or functional work assessment, etc). Does this come up regularly in other settings? It seems pretty common in our academic clinics. This is coming from the perspective of a non-forensic trained individual.

This question pertains to established patients who the treating provider knows, not necessarily consultations or initial evals.

Thanks in advance for your input.

functional impairment, functional impairment, functional impairment.

The notion that someone is unable to work because they are "depressed" is completely invalid and would make most people who came of age the 40s and 50s laugh. Subjectively low motivation does not equate to disability. It important to remember that when you are attesting to this, you are attesting to functional disability. If it not to that threshold, then you should simply be filling out FMLA forms

 

[zolof]

Good afternoon colleagues.

I've seen a fair number of patients over the past year (mostly outpatient) who request time off work, short term disability, and sometimes long-term disability. Just wondering what your approach tends to be in these situations, in what situations you refer for outside evaluation (forensic or otherwise), and when (if ever) you as the treating provider assist with long-term disability applications (such as completing LTD insurance forms, writing a disability or functional work assessment, etc). Does this come up regularly in other settings? It seems pretty common in our academic clinics. This is coming from the perspective of a non-forensic trained individual.

This question pertains to established patients who the treating provider knows, not necessarily consultations or initial evals.

Thanks in advance for your input.

You will see many many people ask you to fill these forms in the outpatient community setting. Not in private practice. It is highly variable and we shouldn't be doing them in my opinion, however I did many in the past.

 

[Shikima]

functional impairment, functional impairment, functional impairment.

The notion that someone is unable to work because they are "depressed" is completely invalid and would make most people who came of age the 40s and 50s laugh. Subjectively low motivation does not equate to disability. It important to remember that when you are attesting to this, you are attesting to functional disability. If it not to that threshold, then you should simply be filling out FMLA forms

The caveat is I do complete the short-term disability forms for those going into IOP.

 

[TexasPhysician]

I don't see any issue with STD with intensive treatment. For LTD, the disability must be quite clear or I refer.

 

[erg923]

I don't see any issue with STD with intensive treatment. For LTD, the disability must be quite clear or I refer.

The recommended/clinically indicated level of care (LOC) from the treatment provider can help support/indicate the presence of mafrked functional impairment. But the LOC itself cannot be used to justify the STD.

 

[Shikima]

The recommended/clinically indicated level of care (LOC) from the treatment provider can help support/indicate the presence of mafrked functional impairment. But the LOC itself can be used to justify the STD.

Symptoms and functional impairments determine the correct course of action, higher level of care. STD is just ensuring they're able to meet their needs while off of work. One less stressor is how I see it.

 

[tr]

functional impairment, functional impairment, functional impairment.
The notion that someone is unable to work because they are "depressed" is completely invalid and would make most people who came of age the 40s and 50s laugh. Subjectively low motivation does not equate to disability.

Have you never seen depression-related impairments to cognition and attention that would prevent someone from doing their job??

 

[erg923]

Have you never seen depression-related impairments to cognition and attention that would prevent someone from doing their job??

yes. Generally needed ECT and/or were catatonic.

 

[smalltownpsych]

The town I work in has a lot of railroad employees and if they are depressed and suicidal, we don't want them running the train.

 

[WisNeuro]

Have you never seen depression-related impairments to cognition and attention that would prevent someone from doing their job??

There are no objective cognitive impairments in functioning with depression. There are subjective complaints with low effort and motivation, though.

 

[st2205]

Have you never seen depression-related impairments to cognition and attention that would prevent someone from doing their job??

I've never seen any that got better while they're getting paid to not work.

 

[Shikima]

I've never seen any that got better while they're getting paid to not work.

That's Malingering.

 

[WisNeuro]

That's Malingering.

I'd agree that some of it is malingering, some of it is reinforcing the sick role/impairment. Some people know exactly what they are doing, some have just been behaviorally shaped to do so.

 

[st2205]

I'd agree that some of it is malingering, some of it is reinforcing the sick role/impairment. Some people know exactly what they are doing, some have just been behaviorally shaped to do so.

Nevertheless, work excuse is rarely an effective treatment regardless of etiology.

 

[WisNeuro]

I wholeheartedly agree. We shouldn't be reinforcing the myths of impairment with many of these patients. Unfortunately, I feel as if I'm in the minority with that particular notion in the healthcare systems I've been in.

 

[Shikima]

So this person who works at a US megacorp was on sick leave due to severe psychosocial distress, completed IOP and went back to work. The onsite doctor does an eval on them and states the person must be off of work for another month, not ready to go back. Now said megacorp rep's are calling my office saying that I need to continue the person on sick leave or said person won't be paid. I'm thinking, you must be a special kind of stupid, it's the facility doctor's responsibility. He did the eval and made the recommendation.

What am I truly missing in this?

 

[smalltownpsych]

So this person who works at a US megacorp was on sick leave due to severe psychosocial distress, completed IOP and went back to work. The onsite doctor does an eval on them and states the person must be off of work for another month, not ready to go back. Now said megacorp rep's are calling my office saying that I need to continue the person on sick leave or said person won't be paid. I'm thinking, you must be a special kind of stupid, it's the facility doctor's responsibility. He did the eval and made the recommendation.

What am I truly missing in this?

Some type of government involvement to take it from the merely stupid to the downright ridiculous.

 

[Shikima]

Some type of government involvement to take it from the merely stupid to the downright ridiculous.

 

[tr]

The town I work in has a lot of railroad employees and if they are depressed and suicidal, we don't want them running the train.

Exactly. Germanwings mean anything to anybody here?

There are no objective cognitive impairments in functioning with depression. There are subjective complaints with low effort and motivation, though.

I'm not a neuropsychologist but I have repeatedly sent patients with subjective memory complaints for neuropsych testing and gotten evals back with impairments in learning/retrieval or attention/executive function (but with normal effort) that the neuropsychologist ascribes to the active depression.

I've never seen any that got better while they're getting paid to not work.

You and I must be treating very different patient populations then. I see this very often. Exploitation of the benefit, on occasion for sure, but certainly not the majority.

Overall I find it disturbing that people who are actually treating the mentally ill are going around with this level of prejudice against them. My experience is that most people want to be active and productive. Sometimes there are system-based perverse incentives not to improve (service connection in the VA for e.g.) but I don't think it's useful to blame individuals for that.

 

[WisNeuro]

I'm not a neuropsychologist but I have repeatedly sent patients with subjective memory complaints for neuropsych testing and gotten evals back with impairments in learning/retrieval or attention/executive function (but with normal effort) that the neuropsychologist ascribes to the active depression.

.

I wonder if your neuro people do not believe in PVT/SVT testing. Before we tested for this, we thought that depressed people had these deficits. After we developed these tests in the late 90
s/early oughts, we found that all of these deficits are generally explained by poor effort/low motivation rather than any actual objective cognitive deficits. It's all about having an up to date understanding of the literature.

In general, subjective cognitive complaint are terrible predictors of observable, valid, objective complaints. In a variety of conditions.

 

[st2205]

You and I must be treating very different patient populations then. I see this very often. Exploitation of the benefit, on occasion for sure, but certainly not the majority.

Overall I find it disturbing that people who are actually treating the mentally ill are going around with this level of prejudice against them. My experience is that most people want to be active and productive. Sometimes there are system-based perverse incentives not to improve (service connection in the VA for e.g.) but I don't think it's useful to blame individuals for that.

I don't doubt most people want to be active and productive. It's part of ambivalence. They have reasons to be active and they have reasons not to be. In my experience, the reasons to be active are very much in their conscious awareness (even making them feel more depressed) but reasons to not be active and productive are very much unconscious and not infrequently can be the default despite the miserable experiences that accompany them. I have great compassion for those legitimately disabled for psychiatric reasons and can't work. It's just that I don't see that as a result of depression alone and I have never seen LTD help that and, almost exclusively, is a large contributing factor to the perpetuation of poor quality of life and further depression.

 

[Armadillos]

I wonder if your neuro people do not believe in PVT/SVT testing. Before we tested for this, we thought that depressed people had these deficits. After we developed these tests in the late 90
s/early oughts, we found that all of these deficits are generally explained by poor effort/low motivation rather than any actual objective cognitive deficits. It's all about having an up to date understanding of the literature.

In general, subjective cognitive complaint are terrible predictors of observable, valid, objective complaints. In a variety of conditions.

Isn't all this all academic though? Practically speaking I don't care if my surgeon has low effort and poor motivation or "objective" cognitive impairment, I don't want that person cutting me.

Somehow I wouldn't be reassured by having the nurse say, "Don't worry Dr MDD is running an hour late for your surgery, he needs to get a little extra rest because he has been waking up at 3am everyday the last month. Also he has been real apathetic lately, very irritable, looks like he lost 15lbs, is not showering much and started giving away his car collection. But you have nothing to worry about, I assure you his cognition is intact."

 

[Shikima]

What is it with STD companies wanting me to state what their work capacity is? How in the world would I know if they can do their job and if it is mild, moderate or severe in severity.

Unable to assess.

But doctor, you have to complete it.
No, I do not. I haven't evaluated the person in the work environment. I don't know how they are functioning. I don't know what they do. If the STD company wants to pay my hourly rate to observe and take notes, this can be arranged.


My office staff doesn't get it sometimes.

 

[WisNeuro]

Isn't all this all academic though? Practically speaking I don't care if my surgeon has low effort and poor motivation or "objective" cognitive impairment, I don't want that person cutting me.

Only academic if you call it that. The etiology of the complaints and the actual nature of them changes treatment. Whereas some people used to thing that cognitive retraining was necessary in such individuals, but ultimately useless. Whatever you call it, some people may not be able to function at a certain level necessary for their job functions, but how we treat that can vary greatly depending on the etiology and actual observed deficits.

 

[Therapist4Chnge]

What is it with STD companies wanting me to state what their work capacity is? How in the world would I know if they can do their job and if it is mild, moderate or severe in severity.

Unable to assess.

But doctor, you have to complete it.
No, I do not. I haven't evaluated the person in the work environment. I don't know how they are functioning. I don't know what they do. If the STD company wants to pay my hourly rate to observe and take notes, this can be arranged.


My office staff doesn't get it sometimes.

I wish I could like this post more than once.

 

[PsyDr]

What is it with STD companies wanting me to state what their work capacity is? How in the world would I know if they can do their job and if it is mild, moderate or severe in severity.

Unable to assess.

But doctor, you have to complete it.
No, I do not. I haven't evaluated the person in the work environment. I don't know how they are functioning. I don't know what they do. If the STD company wants to pay my hourly rate to observe and take notes, this can be arranged.


My office staff doesn't get it sometimes.

They are asking this because by law the disability company is required to pay for an independent medical examination. This includes social security. And they are required to provide a job study that meets federal requirements. Since most employers don't actually have a job study, and disability companies can save a few grand by asking a provider to just fill in a form, they save some cash. Providers who do this create liability by billing a healthcare insurance for nonhealthcare purposes, and not using professional standards when making such a determination.

 

[tr]

I wonder if your neuro people do not believe in PVT/SVT testing. Before we tested for this, we thought that depressed people had these deficits.

Nope they do and they include these data in their reports (hence my specification of 'normal effort' in my post above).

I don't doubt most people want to be active and productive. It's part of ambivalence. They have reasons to be active and they have reasons not to be. In my experience, the reasons to be active are very much in their conscious awareness (even making them feel more depressed) but reasons to not be active and productive are very much unconscious and not infrequently can be the default despite the miserable experiences that accompany them.

If you think that's the case, as a skilled psychiatric practitioner you should be able to use motivational interviewing to bring those conflicting motivations to active awareness and help the individual find the course of action that's best for them. Not convey that you think they are trying to bull**** you into getting them a paid vacation.

I have great compassion for those legitimately disabled for psychiatric reasons and can't work. It's just that I don't see that as a result of depression alone and I have never seen LTD help that and, almost exclusively, is a large contributing factor to the perpetuation of poor quality of life and further depression.

You've made a huge leap from STD to LTD there. You said you've "never seen any that got better while they were being paid to not work." Does that mean you are thinking only of individuals who obtained LTD for psychiatric impairment? In that case there certainly isn't much incentive to attain normal functioning, but the only people I've ever seen who had LTD for psychiatric impairment had chronic psychotic disorders and were pretty obviously incapable of working or even caring for themselves at a basic level. Have you really never seen a previously high-functioning individual who had an episode of major depression, took some time off work in the course of treatment, and returned to their normal high level of functioning afterwards??

Only academic if you call it that. The etiology of the complaints and the actual nature of them changes treatment. Whereas some people used to thing that cognitive retraining was necessary in such individuals, but ultimately useless. Whatever you call it, some people may not be able to function at a certain level necessary for their job functions, but how we treat that can vary greatly depending on the etiology and actual observed deficits.

That's reasonable, but, ahem, rather different from your assertion above that people with depression are either malingering or seeking the sick role.

I'd agree that some of it is malingering, some of it is reinforcing the sick role/impairment. Some people know exactly what they are doing, some have just been behaviorally shaped to do so.

 

[WisNeuro]

That's reasonable, but, ahem, rather different from your assertion above that people with depression are either malingering or seeking the sick role.

Not asserting that at all, you filled in that gap. People fail validity tests all of the time, for a variety of reasons. I was just remarking on some that I see and stating the fact that there is just no good evidence to support the presence of objective cognitive deficits in depression.

 

[SeniorWrangler]

I look at it from a simpler perspective: how do you like doing work that you won't get paid for and that will make the patient mad if they don't get their desired outcome?

If the patient has a serious mental illness and really needs the help, I strongly prefer to fill it out with them, during a visit, so that a) I am getting credit for the work I am doing and more importantly
b) the patient is able to provide detailed input and knows what I am writing on the form.

 

[WingedOx]

Nevertheless, work excuse is rarely an effective treatment regardless of etiology.

100% service connection for MDD is a great way to f-ck someone up for life...

 

[TexasPhysician]

I look at it from a simpler perspective: how do you like doing work that you won't get paid for and that will make the patient mad if they don't get their desired outcome?

If the patient has a serious mental illness and really needs the help, I strongly prefer to fill it out with them, during a visit, so that a) I am getting credit for the work I am doing and more importantly
b) the patient is able to provide detailed input and knows what I am writing on the form.

In private practice, we certainly do bill for it.

 

[thoffen]

I do inpatient now, so it's a clear no if it ever gets whispered. I do think, however that we need to be proactive in these discussions and make clear recommendations on what you think is in the interest of the patient and why. A passive spiral to further dependence on the system isn't that much different than one on substances. Often people are sharing their internal conflicts about their ability to care for themselves, whether they'll ever get better, whether you believe in them, whether someone will notice and stop them from hurting themselves, etc. This being an unhealthy expression shouldn't preclude you from giving your attention to it. It informs you of the patient's ambivalence, limited self-efficacy in the matter, and unconscious recognition that you can help them with it.

Sometimes also I help with FMLA, employer or school letters, etc. because it is in fact indicated.

And if someone is not ambivalent and is simply malingering than saying no is all you can do. Unfortunately, people with strong desire for these benefits will be able to get them in the end.

 

[PsyDr]

I look at it from a simpler perspective: how do you like doing work that you won't get paid for and that will make the patient mad if they don't get their desired outcome?

If the patient has a serious mental illness and really needs the help, I strongly prefer to fill it out with them, during a visit, so that a) I am getting credit for the work I am doing and more importantly
b) the patient is able to provide detailed input and knows what I am writing on the form.

In private practice, we certainly do bill for it.

The issue is not getting paid. It is getting paid by whom.

As a professional you absolutely should be paid for your services. If you are paid by a healthcare insurer, you have signed a legally binding contract indicating you will be paid for clinical services but not forensic services.

I would implore you to protect yourself by not billing healthcare insurance for forensic purposes. By doing so, you are limiting your own professional prestige, earning potential, and economic safety because a private company wants to put their earning potential over your interests. I promise you, things are changing.

 

[Armadillos]

Just to be sure I'm understanding, lets say you have a working patient you know well and have taken care of for awhile, they have a severe acute decompensation and both you and the patient feel they are unable to currently work. They have short term disability paperwork in hand. What is everyone saying I should do?

 

[TexasPhysician]

The issue is not getting paid. It is getting paid by whom.

As a professional you absolutely should be paid for your services. If you are paid by a healthcare insurer, you have signed a legally binding contract indicating you will be paid for clinical services but not forensic services.

I would implore you to protect yourself by not billing healthcare insurance for forensic purposes. By doing so, you are limiting your own professional prestige, earning potential, and economic safety because a private company wants to put their earning potential over your interests. I promise you, things are changing.

I agree in that I would not bill a health insurance company for disability work.

 

[PsyDr]

Just to be sure I'm understanding, lets say you have a working patient you know well and have taken care of for awhile, they have a severe acute decompensation and both you and the patient feel they are unable to currently work. They have short term disability paperwork in hand. What is everyone saying I should do?

Tell the short term disability insurer that your professional ethics prohibit you from determjjjng disability and that they need to have an ime that adheres to the return to work guidelines and federal law.

 

[TexasPhysician]

Just to be sure I'm understanding, lets say you have a working patient you know well and have taken care of for awhile, they have a severe acute decompensation and both you and the patient feel they are unable to currently work. They have short term disability paperwork in hand. What is everyone saying I should do?

I won't tell you what to do, but if it were me and I knew the patient well, I would discuss the parameters of the paperwork. If I felt comfortable with it, I would inform the patient of the fees associated for my time to complete the letter and if needed another appt to further assess everything needed. I would also discuss that such worsening in condition requires frequent FU with myself and a counselor to achieve remission and return to employment as quickly as possible.

What upsets me is when the disability insurance company faxes me the paperwork directly and tries to convince my office staff that I should do it for free. Hahaha, rightttttt.

 

[tr]

Tell the short term disability insurer that your professional ethics prohibit you from determjjjng disability and that they need to have an ime that adheres to the return to work guidelines and federal law.

Sure, if you want your patient's claim to be denied this is a great way to get it to happen without bearing the responsibility yourself. The physicians who perform 'I'MEs are retained and paid by the insurance company and as a rule, if they frequently find that claims should be paid, they shortly will find themselves no longer employed by that insurance company.

Armadillos specified that s/he thought the leave was medically appropriate. In that case the best way to actually obtain the leave is to fill out the paperwork oneself. I generally do this in front of the patient, during their regular appointment time and with their input.

By the way short term leave from work is governed by state law not federal.
U.S. Department of Labor -- ODEP - Office of Disability Employment Policy - Publications - Employment Laws: Medical and Disability-Related Leave

 

[PsyDr]

Sure, if you want your patient's claim to be denied this is a great way to get it to happen without bearing the responsibility yourself. The physicians who perform 'I'MEs are retained and paid by the insurance company and as a rule, if they frequently find that claims should be paid, they shortly will find themselves no longer employed by that insurance company.

Armadillos specified that s/he thought the leave was medically appropriate. In that case the best way to actually obtain the leave is to fill out the paperwork oneself. I generally do this in front of the patient, during their regular appointment time and with their input.

By the way short term leave from work is governed by state law not federal.
U.S. Department of Labor -- ODEP - Office of Disability Employment Policy - Publications - Employment Laws: Medical and Disability-Related Leave

1) the patients contractual agreement with his or her disability insurer is not your business.

2) your concern about an ime deciding unfavorably upon your patient is exactly why the AMA and apa (psychiatry) have indicated that treating psychiatrists should not determine disability. A treating physician should absolutely have their patients best interest at heart, which is why the courts want an independent examiner.

3) I would hope that if you decide to go against professional ethics, you would at least acquaint ourself with the professional standards for how disability is determined. Otherwise one is just violating professional ethics and practing in an manner inconsistent with standards of care. Hint: AMA has some books about the subject.

4) there is a huge body of literature indicating that being off work is harmful to people and that working has a positive effect on longevity, psychiatric illness, weight, etc. hopefully, the serious implications of disability would be balanced between the near term and long term effects with the return to work guidelines being used.

5) return to work is not exclusively determined by state law. At least so long as your state has a va, any sort of waterway, any sort of railroad, any sort of postal office, any sort of airport, etc. don't even get me started on Indian reservations. Federal law, of which ada is one, requires specific things relevant to fmla.

 

[Armadillos]

Now I'm just confused, best I can tell the absolute standard of care in my community is that Doctors of all specialties will in general fill out short term disability paperwork for their patients if they feel it's appropriate. So all these folks are just completing going out on a limb? Maybe I'm misunderanding what is going on in my community, it hasn't actually come up for me to have an established pt ask for this

 

[TexasPhysician]

Now I'm just confused, best I can tell the absolute standard of care in my community is that Doctors of all specialties will in general fill out short term disability paperwork for their patients if they feel it's appropriate. So all these folks are just completing going out on a limb? Maybe I'm misunderanding what is going on in my community, it hasn't actually come up for me to have an established pt ask for this

In my opinion, just 2 opposing viewpoints. I see both sides as reasonable.

Ideally there is an objective party that determines disability, but in reality that doesn't happen. The IME is often as biased or more than as the treating doc.

Also I oppose the AMA as they are quite out of touch with many docs. This results in physicians having poor political representation.