Am Fam Physician. 2003 Jul 1;68(1):175-180.
I have a patient who had major abdominal surgery a few years ago for a fulminant illness. Not long ago, on his first visit to my office, he handed me a disability form. He said that he had chronic pain and that I needed to get this form filled out quickly because he had no money to live on. My student and I smelled alcohol on the patient's breath.
I could not determine from the operative report or other records whether alcohol played a role in his illness nor do the records indicate why he might still be in pain. Pain could be a consequence of the surgery, but I did not think that it was up to me to decide whether his pain was debilitating. The fact that he had been drinking certainly diminished his credibility with me, even though he insisted that he drank only rarely.
I explained to him that as a physician, I could only report on his medical condition. I filled out the disability form as well as I could, summarizing his surgery, stating that the patient complained of ongoing pain, and indicating that I was unable to determine whether this was a condition that could result in permanent disability.
At his next visit, the patient presented me with another blank disability form. He also showed me a letter from the agency, which stated that the claim was not denied, but that more evidence was needed to prove he was disabled. He gave me the blank form to complete.
Having already provided the facts to the best of my ability, what additional information was being requested? Was I being expected to steer the interpretation of the medical condition in a particular direction? As it happened, subsequent labwork showed abnormalities that allowed me to offer a diagnosis, even if it was an unlikely cause of the actual pain.
I have been told that physicians should just state the facts about our patients, and that someone else will make the disability decisions. Is that correct?
In response to a patient's expression of pain, the physician should remember that symptoms must be related to specific findings. Social Security specifically defines an impairment as one that is objective by some measure and “not only by the individual's statement of symptoms.” If the patient has no hernia, no adhesions, and no wound or bowel complications, and objectively has no reasonable, diagnosable cause for pain, there is really no objective basis for finding a functional limitation, and this fact should be made known to the adjudicator.
If, on the other hand, there are objective abnormalities or diagnoses that could reasonably cause the alleged pain, the physician should state what those objective findings are and how limiting they are to functional capacity (e.g., lifting, standing, walking) in this patient.
It is not clear which agency—a workers' compensation system or Social Security—is requesting more evidence on the patient's disability claim. If the evidence is for a Social Security disability claim, the physician can always call the state office of Disability Determination Services for Social Security (DDS) and ask for clarification. Each of the 50 states has such an office.
For Social Security disability claims, it is not requested of the physician to provide a disability determination. In fact, the determination of disability is legally reserved only to the Office of the Commissioner of the Social Security Administration or its agents. However, Social Security and many other disability programs often request a physician to provide detailed information on the extent of physical impairment exhibited in a patient. In other words, they want to know specific, objective physical findings that would limit the performance of basic work activities such as standing, walking, lifting, carrying, seeing, hearing, etc.
On the form from the disability determination agency (or in a separate note), the physician can document diagnoses and the objective findings he has observed, and he also may offer an opinion regarding the effect of these impairments on functioning. For example, he might state: “Mr. Jones has a 3 × 4 cm reducible, moderately tender, incisional hernia superior to the umbilicus. This hernia becomes large and painful with any exertion over about 20 lb of lifting, based on my observations and his report. He can walk and stand without limitation, but he should avoid lifting objects over 20 lb in weight except on rare occasions.”
Such a statement will tell the adjudicators of the disability claim the extent of the impairment (the hernia) and the degree of limitation it exerts on his life activities, including work. The clinician should avoid using terms such as “disabled” or “totally disabled.” These are not determinations for physicians to make.
Physicians can document impairment and the severity of impairment-related limitations, but unless they are employed by a disability determination service, they should not make administrative disability determinations.
Physicians can avoid wearing the “black hat” of disability determination and tell their patients that they will be glad to document the details of the diagnosis and the impact of that diagnosis on functional capacity, but that the determination of disability is not part of a physician's role and, with regard to Social Security disability, is not within his authority.
In general, it might be helpful to this physician and others in a similar situation to review the difference in definition between impairment and disability.
WHAT IS IMPAIRMENT?
According to the 5th edition of the AMA Guides to the Evaluation of Permanent Impairment,1 impairment is defined as an alteration of an individual's health status; a deviation from normal in a body part or organ system and its functioning.
The World Health Organization defines impairment as “any loss or abnormality of psychological, physiological or anatomical structure or function.”2
The Social Security Administration defines a medically determinable impairment this way: “An impairment that results from anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques. A physical or mental impairment must be established by medical evidence consisting of signs, symptoms, and laboratory findings—not only by the individual's statement of symptoms.”3
In the AMA guides, impairments that are to be rated must be permanent impairments. A permanent impairment is defined as one that has reached maximum medical improvement, is well stabilized, and is unlikely to change substantially in the next year, with or without medical treatment.
These definitions may vary from state to state but generally are consistent with those in the AMA guides.
WHAT IS DISABILITY?
According to the 5th edition of the AMA guides,1 disability is defined as “an alteration of an individual's capacity to meet personal, social, or occupational demands because of an impairment.”
The World Health Organization defines disability as an activity limitation that creates a difficulty in the performance, accomplishment, or completion of an activity at the level of the person. “Difficulty” encompasses all of the ways in which the performance of the activity may be affected.
The Social Security Administration defines disability as “the inability to engage in any substantial, gainful activity by reason of a medically determinable physical or mental impairment(s), which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.”3
Workers' compensation systems usually define disability as a reduction in wage earning capacity as a result of an injury, illness, or occupational disease that arose out of, or in the course of, employment.
Distinguishing impairment from disability is the key to resolving issues such as the one presented in this case scenario. One person could be impaired significantly and yet have no disability, and someone else could be quite disabled with only limited impairment. For example, a person with paraplegia who is wheelchair-bound may be working successfully on a full-time basis as an accountant and therefore not meet the Social Security Administration's definition of disabled. Conversely, a concert pianist with a relatively minor injury to a digital nerve might find his ability to perform basic work activities (playing complex piano concertos) to be severely limited; in some systems, the pianist might meet the defining criteria of “disabled” even though he could do other work.
Disability can be temporary or permanent, partial or total. The physician can make reasonable projections as to how long a patient will experience limitations; for example, for the duration of chemotherapy or, in the case of a degenerative disease, indefinitely.
Various programs have differing categories of disability. A person can be temporarily unable to carry on work activity for remuneration or profit (for example, after trauma, surgery, and intensive care) and be considered disabled under some disability programs, but if recovery occurs within 12 months, that person most likely would not be considered disabled under the Social Security Administration's permanent disability program.
Many workers' compensation systems allow for partial disability; hence the need for the AMA guides to measure the extent of the impairment to normal functional capacity. Social Security, on the other hand, is an all-or-nothing type of program; the administrators of the program (not the treating physician) decide if the claimant is either entirely disabled or not disabled.
A physician can freely state the objective findings and degree to which they have limited the patient's functional capacity, but he does not need to, and is not expected to, make a disability determination.
1. Guides to the evaluation of permanent impairment. 5th ed. Cocchiarella L, Andersson G, eds. Chicago, Ill, AMA Press, 2000.
2. World Health Organization. World Health Assembly. International classification of impairments, disabilities, and handicaps: a manual of classification relating to the consequences of disease. Geneva, Switzerland. World Health Organization, 1980.
3. United States Social Security Administration. Office of Disability. Disability evaluation under Social Security, SSA publication no. 64-039. Retrieved June 3, 2003, from www.ssa.gov/disability/professionals/bluebook.
Please send scenarios to Caroline Wellbery, MD, at email@example.com. Materials are edited to retain confidentiality.
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