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Unethical to not accept patients seeking disability?


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I pose this question to see what some other opinions are.  I work in an interventional pain clinic with two physicians.  As you can imagine I see a lot of patients that are on disability.  The patients that I am talking about are the ones that are actively seeking disability.  I feel as most of these people are here to check treatment boxes so they and their lawyer have a better case to take in front of the disability judge.  Would it be unethical to not accept patients that are actively seeking disability?

 

There have been numerous articles that support that patients do not improve when they are trying to prove that they have a disability.  Now I'm not talking psych problem,  medical illness, genetic disorder and the like.  I'm talking MSK problems that limit their function.

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Believe me I document as best I can to state the facts, but still doesn't seem to matter.  I once had a functional capacity examination performed by a PT on a patient that literally said he could return to his former job as a butcher.  A month or two later he came in with the disability card. 

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Believe me I document as best I can to state the facts, but still doesn't seem to matter.  I once had a functional capacity examination performed by a PT on a patient that literally said he could return to his former job as a butcher.  A month or two later he came in with the disability card. 

With all due respect, you don't present all the facts.  There are multiple aspects to disability, and this person may or may not have had some invisible disability not reflected on the FCE.

 

Unless the entire system is unethical, and I can't see society taking care of our wounded as fundamentally unethical, then it's not unethical for you to participate in it.  Having said that, if you are busy telling the truth, your business will dry up, as word gets around that you're not "their" provider.  Just like DOT physicals, your job in disability medicine is to represent society, not the individual patient: what is the real, demonstrable disability?  Document that, and you're doing your job well... what some bureaucrat decides to do on the basis of your accurate medical report is generally not your problem.  If it is, if you can't ethically participate in a system that sometimes gives money to the non-needy and un-entitled... Well, I challenge you to find a facet of medicine where that *doesn't* happen.

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I pose this question to see what some other opinions are.  I work in an interventional pain clinic with two physicians.  As you can imagine I see a lot of patients that are on disability.  The patients that I am talking about are the ones that are actively seeking disability.  I feel as most of these people are here to check treatment boxes so they and their lawyer have a better case to take in front of the disability judge.  Would it be unethical to not accept patients that are actively seeking disability?

 

There have been numerous articles that support that patients do not improve when they are trying to prove that they have a disability.  Now I'm not talking psych problem,  medical illness, genetic disorder and the like.  I'm talking MSK problems that limit their function.

 

I feel like, in your line of work, these issues come with the territory. Now, I'm not saying that it's right or wrong. However, I will say that I just turned down a lucrative offer at a legitimate pain management practice partially for this reason. Ultimately, I really don't want to deal with that patient population.

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Pain management is not necessarily the proper specialty to decide disability. i would recommend refering to PM&R / occupational med specialist if you are uncomfortable with disability determination

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In school I would always see this one family riding MediCal ( CA Medicaid).  They would come in every other day for some new weird medical thing.....  The husband had been ff of work and he kept demanding we sign disabilty paperwork, but he was fine.  He would complain of foot pain, but walk fine when "no one was looking".  Then when someone was watching his "foot would give out" and he would pathetically fall to the floor.  I was so PISSED at this guy in general and his family.  There was another girl that was 30 years old and she admitted she found a DOC IN A BOX at 18 Y/O to call her disabled.  She was seeing us because she just wanted narcotics.   She told me no PT/MRI/Treatment for it, she told him it hurt and he signed off on the paperwork.   So basically I could not do what you do, and I say from an emotional standpoint don't take them.  I don't know if you can legally refuse them. 

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The majority of people I see are of middle aged and still a functioning member of society or thy are elderly and retired.  Most of them are good people that just want to have some type of pain management in order to become more functional.  For the ones actively seeking disability, I just don't see the point in wasting resources and time on treating them for their MSK complaints. They have no motivation for getting better if they are trying to prove that they are disabled.  I was just curious what others would think about the ethics of not trying to treat these people and telling them they need to find someone else to treat them.  I mean our goals are not their goals.      

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I think patients and providers alike have a misunderstanding about disability. I am not sure I even have a clear understanding.

 

If one is disabled, then one is unable to work in gainful employment due to a physical limitation or a mental disability.

 

It does not mean to me that the person is not to be treated. I guess the ideal situation would be someone who knows they cannot work, are not retrainable or able to pursue other kinds of employment but need some financial support to keep food on the table and clothes on kids, etc.

 

However, disability does not mean to me that one does not participate in care and try their hardest to improve their functional ability, follow health recommendations and participate in life. 

 

I had patients trying to file for disability due to type II DM - seriously????? NO - it is a treatable, manageable condition that requires full patient participation and engagement for a lifetime. If your A1c is 10 and you have neuropathy - do better - try harder - yes, access to some meds is difficult but management is not impossible. Perhaps weighing 450 lbs is part of the problem. Let's talk gastric bariatric surgery or other modifications. I will advocate for a patient as long as he/she is WILLING TO PARTICIPATE IN LIFE.

 

The ideal disability patient for me was my lady with lupus and joint and kidney issues who was so sun sensitive that waiting for the bus caused a rash. She never once complained. She volunteered at the hospital, made all her appts, never really talked about disability and always did what she could with what she had. 

 

Disability in this sense has a negative social stigma that a lot of patients unfortunately live up to. If a patient wants SSI or SSD - they can google it - download the 60something page guide, follow the instructions, request my records and go see the SSI doc as assigned. I will send records and comment that they are compliant and such but rarely go on to say that the person is 100% disabled unless they have a trach, a respirator or are missing all limbs.

 

Regarding disability and the government whether state or national - no one really seems to be in charge. Providers are not really given education and guidelines for dealing with this stuff. The online guide was the first improvement I have seen in 20 years.

 

Maybe it should be a subject for a FP/IM CME and find those in the trade who know the most about this mess.

 

My very old 2 cents...

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I've had people come in looking to have their forms filled out when I was in FP.  I'd look at why, get the old charts and go over them...if it was a favorable thing, I'd send them in...if it wasn't I'd write it up as such and then discuss with the patient that I saw no reason for them languishing at home at tax payers' expense and give them the option of me ripping the forms up or sending them in and making them look bad in the eye of the provincial welfare folks.  I've had a few that appreciated my candor and a number of others that I never saw again.  One in particular of the latter used to sit and moan in the waiting room and office even when she wasn't the one being seen...old charts showed lack of physio follow up with crappy excuses, negative imaging and BW findings, etc ad nauseum.  My receptionist turned me on to the fact that it never happened if I was elsewhere :-). 

 

As for turning down someone, you'd likely have to check your regulatory college/medical board as to what gives you legit reasons to refuse picking up a patient.

 

SK

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I stopped doing pain management because it is a highly subjective field in that what the patient says drives almost everything. The peripheral issues of drug seeking and disability seeking made it too unpleasant for me. I like problems I can touch, feel, see, hear. A colleague who is a great pain management guy says he knows most of his patients don't take their meds as directed and don't do the other things they need to like stretch, PT, biofeedback and it doesn't bother him. I think you have to have that kind of attitude to be good at pain management...the willingness to be bamboozled some so that the people that really need the help don't get left behind. I'm just not built that way.

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The majority of people I see are of middle aged and still a functioning member of society or thy are elderly and retired.  Most of them are good people that just want to have some type of pain management in order to become more functional.  For the ones actively seeking disability, I just don't see the point in wasting resources and time on treating them for their MSK complaints. They have no motivation for getting better if they are trying to prove that they are disabled.  I was just curious what others would think about the ethics of not trying to treat these people and telling them they need to find someone else to treat them.  I mean our goals are not their goals.      

 

I'm not sure what the ethical dilemma is- if you truly don't believe they have a disability, then in your professional opinion they don't have a disability.  They can disagree with you...but your medical opinion as to their actual condition is not really an ethical dilemma- it's your diagnosis.  What they do with that information is up to them.

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It takes a certain resilience to do pain mgmt. You could not pay me enough. I've dealt with enough losers and malingerers in Occ Med and even in FP. We often get patients in here who want short term disability and FMLA paperwork filled out for "fibromyalgia" or some other nebulous chronic medical condition that is not truly disabling, but they just want to not work and still get compensated for any number of reasons. I hate it and avoid it like the plague, but sometimes you have to do it. I will not willingly enable someone to be a loser or a parasite. If they have a true disability and resultant hardship, then absolutely I will do what I need to help them out. I'm not going to lie for them, but as a provider you can spin things for or against a disability case. The ultimate decision is up to the state or the VA or some bureaucrat.

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The patients who are really irritating are the ones who are on disability for a MSK problem and I am not even aware of it.  They can step up to the exam table, reposition, remove their jackets by themselves, pick up 50# purses and swing them over their shoulders, pick up the baby and the car seat at the same time.  Then I find out they are disabled.  

 

Oh well, I did not have anything to do with their disability certification, but if they come to me to fill out a renewal, the honest exam is dictated and the form is filled out stating the truth.   If they don't like it, I refer them to our PMR physician and OTR evaluation. 

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