A 40-year-old unemployed man with chronic back pain comes to the office for an appointment with a new physician. The patient injured his back in a work accident years ago and has not worked since. He uses marijuana daily to "ease the pain" and admits that a portion of his income goes toward its purchase. The patient says that nothing has changed and asks the physician to sign a disability form so he can continue to collect disability benefits. When the physician asks about his disability and previous treatment, he replies angrily, "I wouldn't be here re-applying for disability if anything had worked" and slams the disability form down on the table. Review of his medical records indicates a normal MRI one year earlier and inconsistent adherence with physical rehabilitation appointments. The patient walks normally with no apparent discomfort or limitations. Which of the following is the most appropriate response by the physician?
In the United States, disability is a form of insurance that is administered by private insurance carriers or by the Social Security Administration. It provides financial assistance to workers who are unable to continue working due to a medical or psychiatric condition. Certification of disability by a physician is usually required by these entities before the benefit is granted.
This patient's demand that the physician sign a disability form presents a difficult situation. Pain is highly subjective and, at this point in the interaction, the physician knows very little about this patient. Possibilities include malingering or exaggeration of extent of disability to obtain benefits, inadequately treated pain, or chronic pain resulting in legitimate disability. This patient may also have had negative interactions with health care providers or a psychiatric condition that contributes to his angry, demanding behavior. The best approach is to politely but firmly explain that determining medical disability requires further assessment of his symptoms, physical examination, and testing if indicated.
(Choice A) Many individuals with legitimate medical disabilities may use substances; it is not a reason to deny disability benefits.
(Choice B) It is premature to suggest that this patient is attempting to commit fraud without performing an appropriate history and physical examination.
(Choices C and D) It is inappropriate to sign the form at this point in the interview without learning more about the patient and his condition. It is incorrect to assume that the previous disability determination was correct and that nothing has changed.
(Choice E) Unless the patient is abusive or creating an unsafe situation, confronting him directly about his anger is not appropriate and will be unlikely to improve the situation.
Educational objective:
Physicians are frequently asked to evaluate whether a patient is entitled to disability benefits. When interacting with demanding patients, it is best to explain that the physician has a responsibility to perform a thorough assessment prior to making this determination.