The Family Physician's Role in Assessing Impairment and Disability
Am Fam Physician. 2008 Jun 15;77(12):1655-1656.
In this issue of American Family Physician, the article by Taiwo and colleagues1 provides a clear approach to assessing impairment and disability. Family physicians have unique and pivotal roles in this process. In addition to assessing and describing the impairment in response to information requests from external agencies (e.g., workers' compensation insurers, disability policy insurers, the Social Security Administration), family physicians play an even greater role in serving their patients, who should be advised about their objective level of impairment and its functional implications so they may adjust their work and home activities accordingly. For example, a protective “lifting restriction” is as important when shopping in the grocery store as it is when working in the workplace; patients with asthma benefit from advice about school and hobbies, as well as work activities.2
Early and objective communication about the extent of impairment and its consequences has long-term influence upon patients' self-assessment of their functional status.3 The ability to influence the long-term outcome is particularly great for physicians who are trusted by their patients.4 Many patients have already firmly established their beliefs about how severely they are affected before they visit an independent medical examiner.
Taiwo and associates appropriately emphasize the role of physician objectivity.1 Whether serving as an independent medical examiner for a one-time visit, or participating in the assessment of a long-term patient, the credibility of the physician depends upon objectivity. A patient may intentionally or inadvertently overstate the extent of impairment to facilitate a compensation payment, or may inappropriately underestimate the degree of impairment to obtain a job. Therefore, physician objectivity that is occasionally aided by a formal consultation to a physiatrist to assess function in detail or to a psychiatrist to assess whether there is an underlying psychiatric disorder is important. Primary care physicians' objectivity and credibility may reduce the adverse impact of compensation claims on long-term surgical outcomes.5
An impairment evaluation is most useful if it is communicated clearly to everyone involved. Careful communication is particularly important in this realm because nonclinical administrators, rather than physicians, often use the report. The physician may need to translate medical jargon into terms that are understandable by others; conversely, the physician should be familiar with general terminology used by administrative agencies. Taiwo and colleagues carefully point out the importance of the precise use of terms such as temporary, permanent, intermittent, impairment, disability, causation, and apportionment.1 There is a huge difference between saying that something is “probably,” versus “possibly,” caused by work; as physicians, we frequently use these terms almost interchangeably, but a 51- versus 49-percent likelihood can affect access to health care and other benefits.
Assessing impairment is not the same as determining the diagnosis. For example, a nonreversible reduction in the forced expiratory volume in one second may have many causes (e.g., smoking-induced chronic obstructive pulmonary disease, genetic variants, chemical-induced bronchiolitis obliterans). However, the functional impairment is the same. Efforts to establish the underlying diagnosis may be less important than a careful determination of the functional status. As the article's authors point out, special tools such as the Functional Capacity Evaluation may be needed for evaluating impairment.1
The authors also mention the assessment of causation. This should not be confused with describing impairment and disability. Causation assessment may be based on answering three questions6: (1) What is the actual diagnosis?; (2) What exposures were present, and have they been scientifically associated with the health effect?; and, (3) Are there any other likely explanations? For example, headache is common, even in the absence of occupational exposures, whereas malignant mesothelioma is rare in the absence of asbestos exposure. In addition to helping the individual patient, identifying a “sentinel case” may help protect others who would otherwise remain exposed.
In summary, primary care physicians have important roles in evaluating, describing, managing, and preventing impairment and disability. A small investment in learning the basic concepts and terminology will pay significant dividends for patients, employers, and public credibility. The article by Taiwo and colleagues1 contributes to such knowledge.
1. Taiwo O, Cantley L, Schroeder M. Impairment and disability evaluation: the role of the family physician. Am Fam Physician. 2008;77(12):1689–1694.
2. American Thoracic Society. Guidelines for assessing and managing asthma risk at work, school, and recreation. Am J Respir Crit Care Med. 2004;169(7):873–881.
3. Stay-at-Work and Return-to-Work Process Improvement Committee. Preventing needless work disability by helping people stay employed. J Occup Environ Med. 2006;48(9):972–987.
4. Radosevich DM, McGrail MP Jr, Lohman WH, Gorman R, Parker D, Calasanz M. Relationship of disability prevention to patient health status and satisfaction with primary care provider. J Occup Environ Med. 2001;43(8):706–712.
5. Harris I, Mulford J, Solomon M, van Gelder JM, Young J. Association between compensation status and outcome after surgery: a meta-analysis. JAMA. 2005;293(13):1644–1652.
6. Harber P, Shusterman D. Medical causation analysis heuristics. J Occup Environ Med. 1996;38(6):577–586.
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