Monday, December 28, 2015

I Owe You What?

The question of agency in psychiatry is an interesting one.  To me, it's clear: I'm the agent of my patient, it's his best interest that I care about.  But the odd thing is that society periodically asks me to assess patients for their interests. 

 Is my patient able to serve on jury duty?  He tells me he's very anxious, in fact he's taking medications for anxiety, and he has some health issues, and everything about jury duty is hard here in the grand city of Baltimore.  There's a daily stipend; it doesn't cover the parking fee.  You have to negotiate downtown traffic, park in a garage, walk to the courthouse, and if you're put on a criminal trial, there is the fear (albeit the risk is perhaps quite small) that you or your family could be in danger if you vote to convict a gang member.  The seats in the waiting room are uncomfortable, the temperature is always wrong --either way too hot or way too cold. Serving doesn't mean you'll ever be called to a court room, I've spent 8 hours in a freezing waiting room to then be dismissed at the end of the day.  Okay, but here it's not the court asking, it's the patient asking -- but the point is that if I say someone can't serve, they get a free pass. 

What about driving? Periodically, someone gives me a form to fill out for DMV regarding their safety to drive because they carry a psychiatric diagnosis .  I'm not aware of any purely psychiatric diagnosis --with the exception of dementia --which leaves one unable to drive, and invariably the patients does wish to continue driving. Driving helps get to appointments and to obtain medications and food, among other things. Usually it's people with schizophrenia or bipolar disorder who show up with the forms.     I have never witnessed any of my patients drive; if I did, I still wouldn't know how to judge; driver safety assessment is not taught in medical school.  And many patients talk about having multiple accidents, unrelated to any diagnosis or substance issue (they're just lousy drivers) and they never show up with forms. 

A difficult one is the people who show up with forms for clearance  for a new job.  If they are bringing me a form, it means they've told the employer or the human resource folks that they have a diagnosis.  Often, it's my opinion that it would be in their best interest to at least try working --- work adds structure and meaning to a life, it often adds health insurance (a very good thing), and it adds money which allows for food, housing, medications, entertainment, and opportunities for fun, all of which improve mental health! 

 Sometimes, however, I'm not sure if my patient will be able to do the job --- like driving, I was not trained to assess the ability to work.  Sometimes I can see there might be problems -- the patient misses appointments because they get too depressed to get up, or they have executive functioning issues where they simply don't organize their lives well ("Oops, I forgot I scheduled 3 appointments at the same time!").  But still, if they want to work, and if they can, it would be in their best interest.  Now, obviously, there are some exceptions here where it's not in my patient's best interest to take a job -- for example if there's been a history of repeated suicide attempts or violent behaviors, then perhaps it doesn't make sense for me to clear a patient for a job if it requires that he carry a firearm.  But mostly, it's more benign stuff and I've seen people who can't get to an appointment reliably, but can manage a job -- either they prioritize getting to work, or they have jobs that value performance more than punctuality.  And many people negotiate successful work lives around substance abuse problems, especially if they can limit the substances to after-hours.   And there, too, there is a check on the system that doesn't fall on me; jobs where sobriety is crucial usually include drug screening.

So what's my obligation here?  The patient the wants the job.  No one's life will be in danger if she fails, though with some people, job failure can be a huge emotional setback.  The structure, purpose, and money will all be be good if the patient can manage to  work.  But there are these forms that I've been handed with a long check list of  questions regarding the ability to perform tasks where I have no idea, or I suspect that, based on history, the patient may not be able to do --like show up, attend to detail, demonstrate organized thinking-- but I could be wrong, because I have been before, and a work setting is different from a psychiatric office.  If I say I don't think the patient can perform, they don't get the job and they lose the chance to try. 

In my head, it's a dilemma.  There is no question that I am the agent of the patient and that I owe nothing to a patient's potential employer with whom I have no relationship just because they send a packet of papers.  I want what's best for my patient, but as human being, if I have reason to believe the patient can't perform a task and I say they can, then I'm basically lying.  None of it feels right.  

Psychiatrists (and perhaps doctors as a whole) have ended up in these strange places.  We often don't know if our patients can work, serve on a jury, drive, own a firearm safely, go to summer camp, or manage the stress of any given situation.  New settings can be stabilizing or destabilizing.  I'm not sure how we got to be the gatekeepers on such things.

Your thoughts?
So when I'm 


George Dawson, MD, DFAPA said...

I think these forms are a way that risk can be shifted to the physician. In addition to driving one of the riskiest forms I have seen is certifying that somebody can get all of their firearms back. They were typically confiscated by the police in some action that had nothing to do with with treatment. In practically all of the cases I was not the physician of record at the time. People may request an appointment for that specific purpose. My response it to clearly state that this is a law enforcement decision that has nothing to do with me. I take the same position of driving and typically refer people to courses or facilities that can certify their driving based on how they perform on a course.

HR requests have a high mixed agency agenda. Many people including practically all physicians are coerced into signing consent for their employers to obtain embarrassing information about them. That includes information that may directly interfere with their employment status. If I do need to communicate with an employer, I make sure the person I am treating sees what I am sending and I let them know that there is no reason an employer needs to see medical information that is in place for treatment like actual medical records.

This is a difficult area. I have talked with physicians where employers demanded specific records and interventions and were quite assertive about it. I have not had that experience, but agree that it does take time to carefully draft letters and reports that people want.

Anonymous said...

Not really related to your post, but I'm super surprised that you've never told a patient not to drive! My doctor won't let me drive if I'm unwell, and I have to agree. You just don't have the cognitive capacity when you're that unwell. And thinking about it, if she has to write down what happened in the appointment for me because I'm too unwell to remember what she said, managing a moving vehicle seems a bit much. Although this is only an agreement between us, and not something mandated by the state.

Again, not strictly related, but the last time I had a medical before a job,and I had to disclose what medications I took, and therefore the implication that I have a mental illness. It actually raised the question of reasonable accommodations in the workplace if I got sick again. My boss doesn't know what my chronic illness is, but now if I get unwell again I can negotiate a reduced load if I need it. Similarly for university. Perhaps these forms can open a conversation and allow the employee to tailor the job to their capabilities....? (or am I the most naive person on the planet?)

Also totally unrelated, but did you know that in the application form for a visa for China, you need to disclose if you have a mental illness? They don't ask about any other medical conditions. Still haven't decided if I will tick that little box or not......

Dinah said...

George: So what do you do when a patient says "I don't want my potential employer to know that I suffer from schizophrenia? It's all hard.

BecB-- I do tell people not to drive, or not to go to work when they are delusional, or not to walk on the ice when they are frail, or not to drink and drive. Giving medical advice is different than answering questions that an agency asks for. Does China define what a mental illness is?

Anonymous said...

A little late, but no, the visa form didn't give any details.
But I ticked the box and got my visa anyway! :-)

I'm now also facing the joy of loosing my license as our licensing authorities have decided that people with ('severe') mental illnesses can't be trusted to drive. Seriously, I declared my illness to the rta and now I might end up loosing it. Never had a speeding fine or drink driving. Just got caught crying whilst stopped in a loading zone. So not happy.