Disability forms and third-party reports
Online posting: January 30, 1997
Published in print: Mar. 15, 1997 (CMAJ 1997;156:764)
Re: Disability payments continue to climb: "Tell us what you see, not
what you think," CPP tells MDs, by Nicole Baer, Can Med Assoc
J 1997;156:61-4 [full text / en bref]
I found this article quite informative. To those of us "in the
trenches" it has seemed that requests for disability forms and
third-party reports have been increasing, and the exact burden to
the Canada Pension Plan (CPP) is indeed impressive. The article
also struck an important chord in its description of the
fundamental alterations of the physician–patient relationship
once a disability form enters the equation.
It is important to point out, however, that the statement
"Just the facts, please" is inappropriately simple. Much of
clinical medicine relies on the patient history. In every
clinical encounter physicians covertly or overtly judge how
reliable that patient history is. Rarely do we assume that the
patient is deliberately misleading us. The relationship is one of
trust. We trust the patient to give us enough clues to arrive at
an appropriate diagnosis, and they trust us to recommend
reasonable and appropriate therapy based on that diagnosis. This
works well until there is obvious secondary gain for the patient,
but patients who intend to mislead are rarely obvious. Frequently
we suspect that the patient might be misleading us when the
current history conflicts with other facts we have gathered about
the patient. Often these are intimate personal details that were
divulged in "privileged" prior clinical encounters, which were
based on trust. Should this privileged information be passed
along to third parties?
In addition to this, we can rarely test the accuracy of a
patient's statements of function through an ordinary office
encounter. We may find that a shoulder moves normally, with
minimal pain, when we examine it, but of what relevance is such a
finding to an electrician who complains that his arm goes numb
when he works with his hands above his head for more than 20
minutes? Likewise, we can assess grip strength but we have no
adequate way to test whether a patient can function in the
kitchen, as I suspect few physician's offices are equipped with
the saucepans and utensils needed to conduct such a test.
Physicians are frequently and inappropriately asked to
extrapolate from simple office manoeuvres in making assessments
of function that will determine a patient's eligibility for
disability payments. We are also inappropriately asked to judge
the severity of this loss of function. And we will continue to be
asked because we, as a group, are far too willing to provide such
opinions, even though the setting provides limited and flawed
information. Do disability carriers not have a duty to develop
simple, reliable and accurate clinical tests that can be
completed in the physician's office to aid in making these
decisions?
In the meantime, it is the physician's duty simply to report
the facts, "as the patient reports them." Physicians should not
have to judge the veracity of patients' statements. As well,
until there are some agreed-upon methods that all physicians can
use, we should not have to make arbitrary extrapolations about
function based upon simple clinical tests.
Paul M. Peloso, MD, MSc
Royal University Hospital
Assistant Professor of Medicine
University of Saskatchewan
Saskatoon, Sask.
pelosop@duke.usask.ca
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