Disability.....thoughts.

[physasst]

The disabled population is interesting. After being in medicine for over 20 years, I have seen more than my share of persons on disability. The common thought is that they are all "scamming" the system and manipulating it for secondary gain, but there is much more to it, and it is much more nuanced. I have seen patients who deserved disability get it, those who didn't deserve it get it, and conversely, those who deserved it but didn't get it (yes it... happens, and more than you might think) and those who didn't deserve it, get denied.

 

What's interesting is following this last group of people, and some of them, we get back to work. Many of them though, though, despite losing their house, going through a divorce, losing everything and basically losing their life, without the possibility of renumeration, still cannot return to work. I watched one patient fight against her disability denial for over ten years....never succeeding. She still hasn't worked. This argues directly against the secondary gain phenomenon..

 

Physically, we know that they can work, but mentally, they simply cannot. Some of them will even say that regardless of whatever happens, they don't think they could ever see themselves going back to work. Whether this is due to labeling, depression, etc., it is interesting to watch. I've tried to tie together some of the behavioral traits that might tie this together (Satisfaction with job prior to injury, etc.) but there simply isn't a clear trail. Kinda like the alcoholic that cannot put the bottle down, even though his whole life is crumbling around him, a subgroup of these people simply cannot ever mentally function in a workplace again, even if physically, they are okay.

 

I don't think we in medicine understand this well, and there is the temptation to simply say that they are all "lazy", but there is a lot more to it. Just ruminating on this this fine afternoon.......

 

[EMEDPA]

a few thoughts..some folks truly are disabled and unable to work. I get that.

other folks could work without any special accomodation.

the tough ones are the folks in the middle ground who could work with accomodation or job retraining, etc. for those folks it's basically a question of "do you want to work" and are you willing to do what it takes to get back to work.

I saw a guy last night just a few years older than me who is on full disability after what appears to be a minor stroke a few years ago. he has some numbness in his dominant hand and leg. surely there must be some work a guy in his 40s can do with a numb hand. I get that he can't do certain jobs anymore but couldn't he be a telemarketer or something?

I've had thoughts( I'm sure you all have) about what would I do if I had an xyz injury and could no longer work as an em pa. most of the time the answer is teaching, etc.

I can't see not working unless close to 100% disabled and bed bound. the next 60 years would be pretty boring living off social security disability and watching bad daytime tv...

[physasst]

a few thoughts..some folks truly are disabled and unable to work. I get that.

other folks could work without any special accomodation.

the tough ones are the folks in the middle ground who could work with accomodation or job retraining, etc. for those folks it's basically a question of "do you want to work" and are you willing to do what it takes to get back to work.

I saw a guy last night just a few years older than me who is on full disability after what appears to be a minor stroke a few years ago. he has some numbness in his dominant hand and leg. surely there must be some work a guy in his 40s can do with a numb hand. I get that he can't do certain jobs anymore but couldn't he be a telemarketer or something?

I've had thoughts( I'm sure you all have) about what would I do if I had an xyz injury and could no longer work as an em pa. most of the time the answer is teaching, etc.

I can't see not working unless close to 100% disabled and bed bound. the next 60 years would be pretty boring living off social security disability and watching bad daytime tv...

 

It's more than that E. There is a whole psychosocial component to this that we just don't understand. It's almost as though the disability becomes an addiction, a label, that a subgroup of people cannot ever let go of.

 

Honestly, I don't even think for many of them, that this is concious decision. Sure, are there malingerers? Of course. But many of these people are not. They lose their whole lives to this disability that isn't physical, but rather emotional and psychological. It's not deliberate, but a sort of pathology that we in medicine and society just don't understand well.

[G. Davenport]

Lets not forget the accountability we, as providers, have in the ongoing disability debate. It's so easy to sign a form, moving them closer go disability snare. It's much harder to review criteria and present an honest evaluation.

 

 

Sent from my iPhone using Tapatalk

[EMEDPA]

Lets not forget the accountability we, as providers, have in the ongoing disability debate. It's so easy to sign a form, moving them closer go disability snare. It's much harder to review criteria and present an honest evaluation.

 

 

Sent from my iPhone using Tapatalk

that's one of the nice things about working in em. I never put anyone on permanent disability. the 2nd time I see someone for a work comp injury I refer them to occ. med. The er is not the place for an ongoing discussion about longterm disability.

[GetMeOuttaThisMess]

Slightly off topic, this is one of the reasons why I keep current a long-standing disability policy that I pay for since it covers me with regard to my ability to function in my trained capacity (I can think of quite a few snide comments to that statement).  If I lost the ability to practice medicine, though could still work driving my ultimate goal of the yellow baseball cap NAPA Auto Parts truck, I receive my disability payout.  Most policies today do not have this type of stipulation.  It is all or nothing.

[UGoLong]

You do see all kinds. If you live in a neighborhood with a high volume of Jazzy scooters on the sidewalk, I suspect you might look on disability as a common ticket out of the working world. 

 

We disable a number of people for severe cardiomyopathy (EF<20% where 55 is normal). Many really want to work and often have very physical jobs. Sometimes their employers can find stuff for them to do that doesn't require heavy lifting, etc. One guy was a surgical tech and the hospital couldn't find anything for him.

 

At the other end of the spectrum is the 30 year with atypical chest pain and a long, negative cardiac workup. She admitted under questioning that she wanted the disability income so that she could afford to go back to school and still support her kids. Clearly there has to be a better solution for someone who wants to better themselves.

[EMEDPA]

Slightly off topic, this is one of the reasons why I keep current a long-standing disability policy that I pay for since it covers me with regard to my ability to function in my trained capacity (I can think of quite a few snide comments to that statement).  If I lost the ability to practice medicine, though could still work driving my ultimate goal of the yellow baseball cap NAPA Auto Parts truck, I receive my disability payout.  Most policies today do not have this type of stipulation.  It is all or nothing.

I get a long term disability policy as a job perk. it pays 50% of my regular salary if I can't work. that + ssdi and I would do ok, although I would try to do some kind of work or volunteering if at all possible.

[Guest Paula]

It's more than that E. There is a whole psychosocial component to this that we just don't understand. It's almost as though the disability becomes an addiction, a label, that a subgroup of people cannot ever let go of.

 

Honestly, I don't even think for many of them, that this is concious decision. Sure, are there malingerers? Of course. But many of these people are not. They lose their whole lives to this disability that isn't physical, but rather emotional and psychological. It's not deliberate, but a sort of pathology that we in medicine and society just don't understand well.

I think you are onto something here with the psychosocial component.  I think of a patient of mine on disability yet she rides her horses daily, competes in horse shows, cleans the barn, gets gastric by-pass surgery, has PTSD and bipolar illness.  Initially years before I started work at my current clinic she tried to get disability for tendonitis in her arms/hands/elbows and the NP here denied filling out the paperwork for her.  The patient went elsewhere and found a doc who did all the paperwork and she was approved for the disability.  I'n not sure if it's for "tendonitis" or for her bipolar illness and PTSD (which by the way she is very stable on with the meds I prescribed for her after consult with our mental health counselor).  The patient just would not give up her quest until she found someone who would say she was disabled.  I don't get it either but  this particular patient would probably get the mental health disability if she was denied it for tendonitis.  

 

After all...when this patient says "I'm naked" every time you rap lightly on the door to let her  know you are coming in  (she's not) there is definitely something psychologically disabling the pt.  IMO.   

[KMD16]

Still off topic...any direction for those of us who's employer doesn't cover disability insurance.....any direction where one could buy own policies...Am sure it comes w/ a heavy price tag.

[gbrothers98]

I have a good friend who used to work in the disability insurance division of a major insurer. This is an area that has undergone a tremendous amount of change over the decades. Most insurers want to sell group disability rather than individual. Individual can be very pricey especially when adding riders on such as covering till age 65 or limiting to solely an occupation ie if I cant work as a PA, I will consider no other options and am disabled.

 

Several ways to lower the cost of disability insurance are to lower the term ie 2 or 5 yrs of payments, expand retraining and other options rather than limit to current occupation, only replace 50-75% of income rather than 100%. Even so, it will usually be much more expensive than a group policy. Other considerations are to sign up for disability insurance for only large debts such as your mortgage and other loans, you are disabled, your mortgage payments keep getting paid.

While I am a big fan of taking vacation, an employers ETO benefit can be accrued and used as a short term disability bank along with any sick or personal time that can be accrued and rolled over.

 

I also believe anecdotally that there are patients that we see that are truly unable to function in the workplace and society, some not at all, some in very limited roles and for short periods of time. I dont think this is laziness though it is easy to believe that and there is a certain segment of the population that malingering is a reality. I believe for some it is personality or anxiety disorders and others it is just their own unclassifiable makeup of unclear etiology. Sure it makes me shake my head but I have realized that any concern or perseverance of issues such as this are not healthy. In a harsher reality, these individuals may be held more accountable but that is not the reality we have created, at least in this country. And if held accountable, what happens to these people? Do you take away all means of support, let them become homeless and a societal problem that we ignore or try to manage otherwise? That was tried in Europe and Asia in the 1930s and 1940s. History shows society is capable of doing horrifying things in the name of building a perfect world.

 

I read an interesting article recently that postulated that future society decades from now would become stratified into the doers and the donts. The donts would be provided a subsistence level of life, have food, clothing, shelter, healthcare but would not work due to an inability to function due to emotional, psychiatric and cognitive/intellectual issues. The doers would work and provide for the donts and themselves. It would be a societal pact much like everyone in a community paying property taxes to ensure children get an education. 

 

While I dont know if this will happen, I do understand the concept of a societal pact. It would be satisfying to have everyone contribute equally. Unfortunately this is not the case. I take solace that I am not in the shoes of patients mentioned in this discussion, it is not where I want to be. I also will focus on my own sense of personal responsibility and not displace it on others I encounter professionally or personally. Not worth the time and effort nor the angst. I do wish there was a clearer path to self improvement for individuals that do not have the benefits I have had in the last few decades that truly want to rise above their current situation. 

 

G Brothers PA-C

[GetMeOuttaThisMess]

Mine is $261/mo. for two separate policies (second was an inflation increase years back) that gets me to about $3500/mo. as I recall.  Premium is fixed.  Note that there are two payment percentages.  70% if you pay the premium and 60% if employer pays it, or so it used to be.

[ventana]

Lets not forget the accountability we, as providers, have in the ongoing disability debate. It's so easy to sign a form, moving them closer go disability snare. It's much harder to review criteria and present an honest evaluation.

 

 

Sent from my iPhone using Tapatalk

 

 

Yup - have seen it all time where a provider just signs a form with out even really understanding what it is... just don't do it unless you understand 1) the guidelines 2) what disability is 3) the patients injury 4) that you TRULY think they are disabled.

 

 

 

You do see all kinds. If you live in a neighborhood with a high volume of Jazzy scooters on the sidewalk, I suspect you might look on disability as a common ticket out of the working world. 

 

We disable a number of people for severe cardiomyopathy (EF<20% where 55 is normal). Many really want to work and often have very physical jobs. Sometimes their employers can find stuff for them to do that doesn't require heavy lifting, etc. One guy was a surgical tech and the hospital couldn't find anything for him.

 

At the other end of the spectrum is the 30 year with atypical chest pain and a long, negative cardiac workup. She admitted under questioning that she wanted the disability income so that she could afford to go back to school and still support her kids. Clearly there has to be a better solution for someone who wants to better themselves.

 

 

more times then not I have seen people trying to work the system.... they don't want to work....   this is the psychology of disability that is odd - they trade off having any hope of a good life to accept the "disabled" label and a check.  Sort of makes me sick and mad all at the same time...

 

 

I get a long term disability policy as a job perk. it pays 50% of my regular salary if I can't work. that + ssdi and I would do ok, although I would try to do some kind of work or volunteering if at all possible.

 

 

BIG ISSUE here is that if the premiums are paid by the employer with pre tax monies, then you will owe taxes on the disability income (bad), but if they are paid with post tax money it is TAX FREE INCOME.  ALWAYS carry you own long term career/field specific disability insurance policy.  I pay about $248/m for  something like $5,000/month benefit - and this would be tax free income.... i can live off 60k after taxes....

 

 

 

a final note, we are not above it as providers.  I know of a Radiologist who got Dx with lymphoma and went on disability since he never again could work around radiation.....  ne now travels the world for fun.  Strange, as i didn't know that Radiologist worked around radiation any more as most the time the Dx guys/gals are sitting in front of a computer screen----- this "disabled Rad" blogged about his travels extensively so he must be okay looking at a screen......

[Guest Paula]

That radiologist must have been incapable of retraining for any other medical job.  Yeesh, he could have been an MA. 

[delco714]

Maybe he was an interventional radiologist?

[JFarnsworth]

I find this topic to be very tricky. How incapacitated does someone have to be to be totally unable to work? At all? Oftentimes I get cynical and think that CTS doesn't mean that a person cannot ever have a job. And I think about the feeling of entitlement that a lot of people have. And the times that a patient told me how they can't do anything at all and yet are filmed playing paintball or rebuilding their truck engine. Or the story about the postal worker who was on disability permanently for back pain and yet was seen completing the Boston marathon (with a pretty good time, no less). 

I also have a patient who is a firefighter, and his plan is to retire on disability. This means that he gets a huge payment every year but can still work in other areas if he wants. His disability payments are tax free. Whatever he does on the side might be taxed, but basically he will be taking home 100,000 + tax free a year, and whatever he does for extra income is taxed without regard to his disability payments. There is something really wrong with this system....

[BruceBanner]

Being in work comp I see this all the time, although I don't do impairment ratings, and I try to stay away from permanent restrictions.

 

However, at any given time I have around 3-5 patients who are dragging their feet and fighting me tooth and nail about having their case closed. It's almost a syndrome of sorts. A few commonalities:

 

-They tend to perseverate on pain. Any pain whatsoever further supports their "disabled" view.

-They tend to be Hispanic, middle aged white women, or low-skilled workers.

-They perceive themselves as disabled, although they usually have ~90% of their baseline function when they reach maximum medical improvement.

-They tend to grow into this sort of bland complacency where they aren't really satisfied with being on worker's comp and  unemployed, but they don't want to return to work either.

-They have almost no accountability in their own recovery. It's always "why cant you fix me??"

 

I see the same syndrome in veterans with disability ratings. Not all, but some. Similar demographics---uneducated, low skilled or they held a fairly menial job in the military. And that's not to negate their service, just a pattern I see. Combat vets or more highly skilled vets (e.g. spec ops, etc) are the complete opposite. They almost don't want a rating.

[ventana]

Maybe he was an interventional radiologist?

 

yes he was, but IR is a fellowship AFTER Dx radiology, therefor he (in my mind) should be working as a Dx radiologist before living off the system....

[delco714]

Repost

[delco714]

Makes perfect sense to me

[GetMeOuttaThisMess]

Maybe I should try it.  "Cognitive memory loss" from statin AND Keppra therapy (why blame just one when I can list TWO).  Or maybe it's more of a matter that we can't keep our studies straight.  Just read where concurrent ASA therapy with COX-2 inhibitors may lessen the CV risks associated with same in women at least, and then I read where it is now felt that ibuprofen is less of a CV risk than naproxen, where it used to be just the opposite (neither was much of one compared to the COX-2 guys)!  I'm so confused....  Could someone please sign some disability papers for me?

[Guest Paula]

C'mon over and I'll sign your papers.  But won't pay for your travel to Michigan.  LOL!

[GetMeOuttaThisMess]

^^^  If I come on my own, can we go to Mackinac Island and see if Jane Seymour is still running around trying to find Christopher Reeve at the Grand Hotel (Somewhere in Time)?  A visit with Jane at the lake's edge would make everything better. 

[chris.shannon77]

^^^  If I come on my own, can we go to Mackinac Island and see if Jane Seymour is still running around trying to find Christopher Reeve at the Grand Hotel (Somewhere in Time)?  A visit with Jane at the lake's edge would make everything better. 

 

Wow!  I'm only 3 years older than that movie.  I guess you're not a child of the 80's.  Maybe 70's?

[GetMeOuttaThisMess]

I was torturing patients in the early 80's with Zomax, chymopapain for HNP's, and still trying to figure out what this immune deficiency syndrome out of Africa was.