Diagnosing for administrative purposes: The process and problems

Diagnosing for Administrative Purposes: The Process and Problems Harvey D. Lomas and Jonathan

D. Berman

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SYCHIATRISTS are required by law and social custom to perform examinations and issue reports answering specific administrative inquiries. The disbursement of billions of dollars in cash and other benefits is contingent on the release of such medical information.‘.2.3 A subsequent determination of degree of impairment or disability, work relatedness of injury or illness, capacity to stand trial, employability or educability is made by adjudicators, judges, juries, insurance claim adjustors, prospective employers or rehabilitation experts who review the medical evidence (reports, charts, etc.). A favorable review leads to the disbursement of cash or other benefits. In spite of the fact that such examinations are commonplace in everyday practice, little is written about them in the psychiatric literature. Furthermore, an informal survey of four medical schools, including psychiatric residency programs involving at least 10 major hospitals, reveals that little or no specific education or training is provided in the performance of such examinations or the issuance of such reports. Nevertheless such examinations constitute a significant part of the professional activity of psychiatrists in both private and institutional practice. The assumption appears to be that psychiatrists who are well-trained in comprehensive patient examination procedures are naturally able to more than adequately perform such certification examinations and issue the accompanying reports, which we shall refer to as certificates. Harrison, et al, write: “Today, with periodic health, pre-employment, and insurance examinations the scope of the physician has been enlarged . . . objective methods of study are all important, for patients tend to emphasize different facts, depending on whether they seek employment, pensions, disability or insurance. It is obvious that the same symptoms will rarely be described in the same way by the soldier desiring release from military duty, by the prospective employee seeking certification of his fitness for work, or by the patient who is alarmed because of fear of serious ailment. The approach to the patient, therefore, must be varied to correspond with the conditions which bring physician and patient together.“4

From the Cinc,innati VA Medical Center, Cincinnati. Ohio and Jerry L. Pert& Memorial Veterans Hospital. Loma Linda, Cul(fornia. Dr. Lomas is Associate Professor of Psychiatry and Chief of Psychiatry, Cincinnati Veteruns Administration Medical Center, Cincinnati, Ohio Dr. Berman is Associate Pmfessor of Psychiatry, Loma Linda University School of Medicine and Chief. Inpatient Psychiatry. Jerry L. Pettis Memorial Veteruns Hospitul. Loma Linda, Cal(fornia. Address reprint requests to Dr. Lomas, Associate Professor of Psychiatry und Chief of Psychiatn/, Cincinnati Veterans Administration Medical Center, 3200 Vine Street, Cincinnati, Ohio 45220. 0 1982 by Crane & Stratton, Inc. OOIO-440X/821230610006$1.00lO Comprehensive

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In this paper, the authors examine one facet of this expanded scope of the physician; the role of psychiatrists in performing diagnostic examinations for the purpose of responding to specific inquiries of an administrative nature. After reviewing the scope of this activity and describing the certification process itself, the authors will discuss the distinction between therapeutic examinations and examinations for administrative purposes, with reference to the sparse existing literature on this topic. THE PROCESS

OF CERTIFICATION

Individuals who wish to claim benefits or privileges of one sort or another from one of the many provider institutions in our society must establish a legal basis for their claim and provide evidence and information upon which a decision to accept or deny a claim can be made. When the evidence or information is of a psychiatric nature a report from a psychiatrist is required (which we have termed a certificate), based on a diagnostic examination (certification examination) of a claimant seeking benefits. Such reports establish a basis for making administrative decisions, e.g., approving or denying a claim for benefits. Among the most common claims made are those for compensation or pension awards. Two of the largest provider institutions are the Veterans Administration’s Department of Veteran Benefits’ and the Social Security Administration.6 Other agencies commonly seeking certificates include: Departments of Motor Vehicles, Departments of Rehabilitation, Boards of Workers Compensation, Boards of Education, Department of Defense, Federal, State and Local Courts, private insurance carriers, Civil Service and private industry. After initiating a claim for benefits, the claimant is ordered to report to an authorized psychiatrist for an examination. Authorized psychiatrists are either fee basis consultants or employees of private or public provider institutions. The claimant automatically agrees to the release of information (issuance of a certificate) for the purpose of assessing and evaluating his mental condition with respect to the specific administrative question posed. Once a psychiatric opinion is rendered, virtually all insurance funds, public or private, depend on independent raters or claim adjudicators, generally not health professionals, to establish degree of impairment and authorize disbursal of funds or benefits. Rating boards are guided in their respective determinations by pre-established rules and guidelines including formats for assessing degrees of mental impairment from documentary evidence.7,8.Y Thus, according to Darby,” adjudicators are the “guardians of the funds” and the certifying psychiatrist is an advocate in an adversary situation. It is important to note that the vast majority of claimant-patients are economically and socially disadvantaged people who depend on a favorable determination for their subsistence. Accurate cost figures are difficult to obtain, but some available figures are illustrative. As of December, 1979, 2,265,294 veterans were receiving compensation and pension benefits, of which 241,865 were determined to be unemployable, thus rated 100% disabled.” In fiscal year 1977, compensation and pension benefits paid to veterans and their dependents amounted to 8.9 billion dollars.5 As of September, 1977, 221,965

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veterans (11.5% of total) were receiving an average $173.26 per month (38.5 million dollars) for psychiatric and neurological diseases, 57,356 of which were for psychoses. Levine and Levine’* estimate the indirect cost of mental illness due to disability to be approximately 7.4 billion dollars in 1971. THERAPEUTIC OR ADMINISTRATIVE DIAGNOSING? It is important to note that the traditional physician-patient relationship with its assumption of confidentiality and the mutual goal of treatment does not exist in the certification situation. However, the historical assumptions of trust and/or the illusion of a therapeutic relationship may still be invoked or utilized, even though by definition, certification refers to a diagnostic examination for purposes other than deciding on a course of treatment or making a therapeutic intervention. While there may be some therapeutic effect or placebo effect as a result of such an examination, it is fortuitous and unintentional; i.e., not part of the explicit purpose of such an examination. In the certifying situation an individual is a claimant rather than a patient, i.e., he is seeking material benefits other than specific treatment for his condition. The Diagnostic

Interview

Review of the psychiatric literature fails to reveal any clear distinction between examinations for therapeutic or administrative (non-therapeutic) purposes. The bulk of literature supports the implicit assumption that, once mastered, the psychiatric interview can be used for a number of purposes. However, representative discussions of interviewing technique clearly reveals an emphasis on therapeutic intent. For example, “. . . the psychotherapeutic intent of the psychiatric interview must be particularly stressed.“‘3 “The ultimate aim (of the psychiatric interview) is to help the patient change his underlying attitudes and accept emotionally what he has heretofore refused to accept.“14 Continuing, “all during the course of making a case study and particularly as the findings are reviewed in the course of constructing a diagnostic synthesis, the experienced psychiatrist is automatically formulating plans in the back of his mind for the treatment.“15 Perhaps the most articulate spokesman for the psychiatric interview was Harry Stack Sullivan. He comes closest to making the distinction proposed here when, for example, discussing diagnostic formulation, he writes, “That is a somewhat unwelcome activity as far as I am concerned if only because I am very much more interested in what can be done than what has happened. The notion of what can be done is determined without particular reference to any particular clinical diagnosis. 1 believe that the clinical diagnosis exists more out of regard for public demand and the professional dignity of the doctor than because of its greatly simplifying effect on psychiatric problems.“‘” Continuing, Sullivan writes, “Diagnosis and prognosis cannot be dissociated from therapeutic consideration . . . the information which one requires for making a diagnosis is most readily secured in a situation oriented to treatment.” Carrying this a step further he writes, “The differences of the interrogation for history taking and establishment of the mental stutus, from the

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therapeutic interview are dually the results of lack of time, inadequate experience, and erroneous preconceptions on the part of the examining physician.” Sullivan reminds us that “the ostensible purpose of the interview” has a determining effect on technique. It may even have a determining effect on the validity of the information obtained. MacKinnon and Michels write, “An artificial distinction between diagnostic and therapeutic interviews is frequently made. The interview that is oriented toward establishing a diagnosis gives the patient the feeling that he is a specimen of pathology being examined, and therefore, actually inhibits him from revealing his problems.” What seems to be missing is a clear cut distinction between purposes: administrative or therapeutic. The Forensic Interview) The literature on forensic interviewing comes close to recognizing the difference between certification and therapeutic examinations. Representatively, Watson writes, “Regardless of the good therapeutic intentions of the therapist, the loss of the patient’s individual decision-making authority makes it necessary that therapeutic decisions for these patients be under control and supervision of the legal system”” Forensic examinations are far removed from therapeutic examinations even though they may determine whether a subject is to become a patient in need of treatment and, in conjunction with the legal system, the conditions and type of treatment to be provided. Research Diagnostic

Examinations

The voluminous literature on research diagnostic criteria, psychiatric rating scales and DSM III, is uniformily directed towards diagnosis for treatment, attempting to define syndromes which have a predictable response to specific treatment interventions. Diagnostic examinations for administrative purposes seem especially well suited for standardized interviewing (RDC) and reporting. However, at present there is little research on compensation, pension or disability examination with regard to outcome. Attempts to characterize psychiatric syndromes based on predictable outcome with respect to typical administrative questions, e.g. long-range employability, might result in a nosology quite distinct from DSM III. The development of such instruments might well contribute to more objective rating’ and better social policy decisions. ‘920 Disability Examinations Standardized, objective measurement of mental disability is a matter of practical social and economic necessity. Yet the literature on assessing psychiatric impairment for determining degree of disability fails again to distinguish clearly between administrative and therapeutic examinations. Furthermore, there is an ever increasing literature which casts doubt on the usefulness of the traditional diagnostic process for determination of disability and rehabilitation potentia1.21.22.23,24.25 Similarly, there is increasing concern ex-

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pressed about the social and psychological effects of such determinations.‘6327328 Of particular concern is the lack of literature and research on the accident in spite of abundant literature on post-traumatic or disability process’9~zo~2’~32 stress disorders, and secondary gain, for example. Perhaps the most difficult problem in diagnosing for disability determination is determining whether the claimant is a malingerer. Miller and Cartlidge” define malingering as, “. . . the term . . . used to encompass all forms of fraud relating to matters of health. This includes the simulation of disease or disability which is not present; the much commoner gross exaggeration of a minor disability; and the conscious and deliberate attribution of a disability to an injury or accident that did not in fact cause it, for personal advantage.” Heinman and Shanfield.32 in writing about the influence of personal values on psychiatric disability assessment write, “A critical and controversial part of the psychiatric assessment is to distinguish the malingerer who consciously rrdl not work from the neurotic who cannot work (if that distinction is acceptable).” Although some physicians feel that malingering can readily be detected,34.35 the overall impact of the literature covering the accident-disability process, disability neurosis or compensation neurosis is an appreciation of the extreme difficulty of separating malingering from neurotic symptomatology (to the extent that this is a valid distinction). The attitude of the “guardians of the funds,” i.e. the adjudicators, and the adversary nature of the process itself suggests a presumption of malingering in virtually every case. Diagnosis becomes a matter of deciding on worthiness and legitimacy, and may therefore be strongly influenced by transference-counter-transference issues. A variation of this attitude is expressed in a brief editorial by D. C. Chiversz3 where he writes, “It is because of this unavoidable bias and because human nature is such that altruistic ideals can be unscrupulously exploited, that a doctor’s certificate should not be regarded as an irrefutable document, indisputable because of its professional source.”

The sparse psychiatric literature in the area of administrative examinations reflects the assumption, made explicit by Harrison, that psychiatrists can employ the same technique and approach in both administrative and therapeutic contexts. However, in the therapeutic situation there is accountability to the patient and oneself through time; in addition, the intent is therapeutic and the consequences of an intervention are measured. In the administrative situation neither the social or psychological consequences are assessed in terms of outcome and the intent is to gather information which will be used to deny or disburse funds or benefits. Considering the ubiquitous nature of administrative evaluation purposes, there is a remarkable absence of research: on the social and psychological consequences of favorable or unfavorable determinations and on other outcome aspects of the certification process. Thus the authors believe that certification, rather than representing one element of an ever-widening scope of medical practice, is a fundamentally divergent activity. It represents an attempt to apply medical technique to

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achieve social and economic solutions which are unrelated to any treatment of a specific disease or disorder. Ultimately, such practice may be viewed as social exploitation of the prestige of the physician. CONCLUSION We have proposed a distinction between diagnostic interviews and examinations of patients for therapeutic purposes and those of claimants for administrative purposes. The disbursal of billions of dollars in cash and other tangible benefits is contingent on the latter while relief of intrapsychic and interpersonal distress is the intention of the former. The failure to distinguish between examinations for therapeutic purposes and those of a forensic or administrative nature has lead to a major deficit in both psychiatric training and research. There is a need for preparing medical students and psychiatric residents to face the social realities of practice which should include knowledge of the distinction between diagnostic examination formats and purposes. There is also a great need for large-scale research into the psychiatric consequences of certification about which virtually nothing is known, and a need to fully air the ethical implications of this practice. SUMMARY Psychiatrists are required by law and social custom to perform examinations and issue reports answering specific administrative inquiries. Disbursing billions of dollars in cash awards and other benefits is contingent on the release of such information. Heretofore, no clear-cut distinction has been made in the literature between diagnosing for administrative purposes versus diagnosing for therapeutic purposes. Considering the widespread practice of diagnosing for administrative purposes, in the absence of a distinctive literature, the assumption appears to be that psychiatrists, by virtue of their training, are suitably trained to perform such examinations. This assumption is not solidly supported in research or other literature, nor is any special training in this activity provided in most graduate and post-graduate psychiatric programs. Because administrative queries differ profoundly from questions addressed in treatment-oriented examinations, a distinction between these two types of examinations appears warranted and should be reflected in psychiatric training. ACKNOWLEDGMENT Thanks to Donald G. Langsley, the manuscript.

M.D. and Lou Ann Wieand. M.A. for their assistance

with

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