Diagnosing For Dollars

Most people don’t seem to understand how disability benefits work – and that includes doctors as well as patients.  There’s a very good reason for that. The system is screwy.

Thinking that your own regular doctor might be prejudiced and just dish out disability benefits ad infinitum so you never have to go to work (Gee – where did the government get that idea?) the patient is sent to an outside doctor to do an evaluation.

I’ve done plenty of those in my day. I’ve done them for veterans and for Social Security and for worker’s comp and even such exotic things as employee plans for large corporations (such as GM and Ford) and unions (like the Railroad Workers).

They are more alike than different.

Let me give you an example – a real person – so you can see how it goes.

A person whose complaint was all-too-typical presented in my office wanting an extension of his disability benefits (and being excused from working) for another three months.  These things are always done in three month intervals so the patient can be re-evaluated and possibly return to work – unless it is a permanent disability due to a grievous injury or some such thing.

He said his problem was depression.

I am one of those rare people who takes the complaint of depression seriously.  Many people – both professionals and lay – consider this excuse a bigger boondoggle than penny stocks.  However, depression can be fatal.  People commit suicide or they neglect taking care of their children or they are so preoccupied at work that they cause accidents.

I have to investigate the claim of depression and see if it is a good diagnosis or not.  I HAVE to.

This patient certainly seemed depressed and he didn’t have enough reason, memory or concentration to go back to work.  Granted, he had taken it hard when he was harassed at work so I advanced him for three more months of disability.

To my surprise, he got very angry at me and said, “The doctors taking care of me said I can’t go back to work for at least a year.”

“Where the hell did they get that idea?” I exclaimed.

That shocked him and he looked at me and said, “Excuse me?”  Apparently he didn’t expect a nice, petite, motherly doctor lady to use such language.

“Where the hell did they get the idea that you can’t go back to work for another whole year?”

Well he didn’t know where they got it except that his doctor and his therapist talked and agreed on it. 

It didn’t make any sense to me and I told him, “Look, you’ve already been out for a long while so statistically if you’re really depressed and you’ve been getting competent treatment, you have a good chance of being nearly recovered.” 

I mean, medical science knows that the average depression is going to last eight months to a year.  This man had already been out six months.  In my opinion, another three ought to tell us a lot about whether he can return to work.

But this fellow was insistent. “It’s going to be at least a year before I can go back to work.” That’s the gospel truth even if he can’t tell me how his doctor or his therapist came up with that.  They are the authorities he wants to believe – not me.

“Ask them to find you studies in the literature,” I told him. “Ask them to tell you why you can’t work for a year because I don’t have the idea that you can’t work for a year and Social Security would never allow a one-year extension all at once.  I don’t know where your treatment team is coming from. You tell me you want to work, so you ought to talk to them and figure it out.”

Well, I think the poor man was still in shock. 

Looking at him more closely, I discovered something else.  His depression wasn’t getting better.

After six months of psychotherapy and doses of antidepressants, I had to question why not. The answer was a fairly common one.

His diagnosis was wrong.

I know that anyone who watches TV and movies and thinks they know all about how psychiatry works will not believe me, but this is a medical specialty – it is backed up by real science and research.

All over the world, people are given estimated times of treatment, times for various stipends like disability based on diagnoses.  Now to get a diagnosis, you have very precise criteria, like a list given in the Diagnostic and Statistical Manual, the most current edition of which is IV with a Text Revision (DSM IV-TR).

I actually went to the trouble of learning this book by heart when I took my boards, but just to be sure, if there is something that I don’t remember, I’ll check on it.  Obviously, nobody else does. 

This man’s primary diagnosis was not depression — it was post-traumatic stress disorder (PTSD). 

He had some things that happened to him at work — things so terrible that even when he tried not to think about them, he still thought about them, so he was avoiding the workplace.  He had intrusive thoughts, sometimes in a nightmare, sometimes during the day when he was thinking about something else. These awful thoughts would overwhelm him.

He also had what is called “hyper-vigilance.”  If there was a sudden noise or sudden occurrence, this man reacted violently. One reason I’ll always remember this man — as I was examining him, a bird flew directly into the window making a magnificent thud, probably breaking its neck and falling onto the ground dead. 

Now I startled a bit because you don’t expect a loud thud while you’re trying to assess a patient, but he started crying, shaking, jumped to his feet screaming and I had to talk him down. 

When someone is hypersensitive to noises or sudden things that happen that make noises, when they have intrusive thoughts and when they rearrange their lives to avoid certain situations, they are batting three-for-three with the cardinal symptoms of PTSD. That little light bulb went on over my head — this was the correct diagnosis — not depression.

It will take a little longer to get better from PTSD than from depression, probably so, but here’s the kicker.  From what he told me, nobody — not his psychiatrist and certainly not his therapist — was using any kind of therapy that anyone had ever reported to be effective in PTSD.

Of course, this diagnosis changed the entire picture.  The patient could get better, with proper treatment (good luck with that!) but how much better could he ever be?  And how long would it take?

The research on PTSD is nowhere near as robust as the data we have on depression.  For one thing, there is – obviously – a heck of a lot of misdiagnosis.  For another, there is a heck of a lot of denial.  One of the primary populations affected by PTSD is the military – troops in combat.  Yet the military doesn’t want to admit to hardly any cases of PTSD.

The reasons range from bureaucratic snafus to conspiracy theories.  Let’s leave that for some other investigative journalism.

Meanwhile, I was confronted with a patient who wanted answers (as did the Social Security folks) and all I had to go by was a lot of conflicting estimates in a variety of publications.

There was a whole new can of worms that opened up wide – and a bunch of doubts and riddles crawling out.

Would he ever be better enough to go back to the same job?  Would he be able to do a different job?  Could he be retrained with new skills?

From his earlier outburst about wanting permanent disability status, I think this man hated his job like poison and had no desire to work.  He would sooner collect a lower amount of money from the benefits and remain on a fixed-income for life.

This is why many disability examiners omit the obvious question: “How long will it take until you get better?”  Most examiners are happy to keep renewing the 3-month extensions as long as the patient has a convincing inventory of symptoms.

In the case at hand, if these people had not made the decision for the length of treatment by the patient’s TRUE diagnosis and weren’t using a treatment that had any chances of working on that accurate diagnosis, can we even hope that the patient will ever get better?

Now, if you’ve ever read anything I’ve written, you know I don’t pull my punches.  I don’t sugar-coat the bad news.  If you are sensitive to the ugly truth, this is your warning to bail out right now.

I’m going to tell you the number-one way that medical treatment professionals will determine how long it takes any given patient to get better – using whatever definition is acceptable – from any given malady.

(If I could afford a back-up band like The Tonight Show, I would tell the band leader to give me a drum roll.)

And now, the answer to the question: When do we dismiss a patient from treatment or the hospital and say they are “better?”

ANSWER: When their insurance runs out.

I was crushed when I learned this.  I had been indoctrinated at school that we did everything we could for the patient, no matter how long it took, no matter the cost. 

And I learned this ugly truth from a mentor, a psychiatrist who I thought otherwise honorable, and to whom I looked up.

Government programs such as Medicare as well as private insurance programs only allow a finite number of days you can be in a hospital (during certain “benefit periods”) and/or how many office visits you can make to a doctor.

That is the honest truth – and I have never seen anyone keep a patient in the hospital without payment just to make them better (Except those saints and paragons of virtue on TV shows – fictional TV shows, that is).

So does everyone think these are objective decisions?  Good God, no!  Right now, virtually everything in psychiatric or psychological treatment is being used to make the maximum money for the doctor or for the therapist and I have no evidence whatsoever that people are asking the question, when can a person get better — let alone what you do with them when they get better?

So if you forget everything else I said and you’ve got a doctor or therapist, the question to ask is, how long does it usually take you to help someone get better when they’ve got my kind of problems?   How long do you think it will take me to get better? 

Unless you’re one of those sick people who likes being sick, unless you like that part of sick row where people worry about you and take more care of you, or unless you like the money you get for being sick — which in these United States — isn’t that great, ask the person taking care of you how long they think it’s going to take to get you better.

And pick a time before that to discuss with the person taking care of you, “How are we doing?  Are we gaining on the goals?  Are we getting where we need to go?”

And if you don’t do that and if no one knows when you’re going to get better, well I guess what I’m saying is, don’t expect your doctor or your therapist to tell you when you’re going to get better. 

Their lives won’t get any better when you get better.  They’re just going to have to find more patients who need the same intensity of treatment, keep their practice full so they can keep their income up.  

Ask your doctors when you’re expected to get better and find out why they think that and how they calculate that.  It may be the first question to start giving you the courage to ask more. 

Remember, you’re the boss and the doctor is an employee, and you are paying their salary, whether you’re doing it out of your pocket or your tax dollar or from insurance you paid into when you were working.  You are the boss and there is something very wrong with your doctor if they can’t tell you when you’re expected to get better. 

And this part is really up to you — you’ve got to know what it’s like when you’re better.  What do you want to do — go back to work doing what you did before, or doing something else with your life?

Remember, you’re the boss and the doctor is the employee and ask for the information you want and need because no one is going to give it to you unless you ask.  Take charge of your illness.