Social Security Disability Evaluations

1. Social Security Disability Evaluations C Donald Williams MD CGP

2. Course Plan • Define SSD Exams and how they differ from other evaluations • Review criteria used by SSA to determine qualification for benefits • Outline how to conduct the exam • Review a sample exam • Sign up instructions

3. Social Security Disability • SSA evaluates applications for SSDI • SSA contracts with state agencies named Disability Determination Services—that contract for and schedule exams • Determinations are based on “impairments” • SSDI (“Insurance”) based on quarters paid into FICA--amount of award proportional • SSI is “needs based”--like welfare • Criteria include “severity” and “duration”

4. S.S. Disability definition • “The inability to engage in substantial gainful activity by reason of a medically determinable impairment which can be expected to result in death or which has lasted or can be expected to last for 12 continuous months.” • Impairments must be severe • 12 months anticipated duration or longer

5. Differences from other IMEs • Social Security—Impairment only • Worker’s compensation—Impairment and causal relationship to work injury • Fitness for duty—Impairment performing the essential tasks of a specific occupation • Personal injury—Determine the nature and degree of impairment with specific tort cause

6. Entry to organizational and occupational psychiatry • All psychiatrists have • Minimum necessary skills to start • The opportunity to work in this area • SSD exams provide psychiatrists… • Income • “On the ground” exposure to the relationship between work, organizations and institutions, and psychiatric health and illness

7. Other benefits • Concentrated practice in efficient assessments of wide variety of patients • Refine conceptualization and writing style • Efficient way to fill gaps in schedule • Entrée to performing other types of disability exams because of community exposure • Service to public sector with few problems

8. How to become an examiner • Telephone contact information for all states • www.ssa.gov/disability/professionals/procontacts.htm • Or type “disability determination services” in Google search engine • States have continuing need for new examiners • Review the SSA-DDS suggested outline for examiners

9. The psychiatric evaluation • Review the medical records • Evaluate applicant face-to-face • Follow the outline—child and adults • Provide specific observations • Present a data driven MSE • Use DSM-IV multi-axial diagnoses • Show respect to the examinee

10. Sample assignment letter • “The claimant alleges depression, anxiety and substance abuse. Provide a full mental status exam detailing objective data, hour by hour activities of a typical day, range of interests, degree of ability to relate to others, to care for personal needs and capability to manage own funds. With treatment, what degree of improvement can be anticipated and the time required?”

11. The form of the evaluation • Use standard format • Adult outline • Child outline • Employ economy of language • Answer the questions

12. The conduct of the evaluation • Applicant signs disclosure forms • Advise of limitations on confidentiality • Advise that you are not their doctor • Do not criticize their medical providers • Record primary data, including direct quotes • Avoid unsupported generalities

13. The place for templates • Create your own template—of categories, not responses--using the SSA format • Saves time--promotes efficiency • You author the relevant information under each heading • Consider using voice recognition software • Requires a >1 Ghz computer with 512 MB memory and a USB DSP microphone (Plantronics)

14. An evaluation template • Review sample report template in your packet....turn to packet • Statement of Non-Confidentiality:  “The claimant was advised that this interview was for evaluation purposes only and that a copy of the evaluation report would be provided to the Social Security Administration. The claimant was further advised that no doctor-patient relationship was established and claimant agreed to continue with this evaluation with that understanding.”

15. Professional conduct • Treat examinee the way you would like your relatives to be treated by a professional—”golden rule” • Provide an evaluation, not value judgments • This is harder than it seems on occasion--examples • Countertransference awareness is helpful—e.g. fear of being like the claimant can lead to devaluation or rescue–-with loss of objectivity • Be SAFE! • If situation does not appear safe, in any respect, cancel the evaluation • Some evaluations should only be conducted in a secure facility or in a public clinic setting

16. When the unexpected happens—transparently document the incident • You don’t realize until the exam has begun that you have known the claimant in another context—e.g. waitress at a restaurant--give claimant the choice not to proceed • The claimant is demanding and won’t leave the office—document what was said and done • The claimant becomes threatening and complaining—use your skills and call security

17. Summary • SSD Exams are good IME practice, and you can start next week • Good entrée to Organizational and Occupational Psychiatry • Obtain a feel for the interface between work and psychiatry—build a mental library of professional experience

18. Where to get more information • www.aoop.org and www.cdonaldwilliamsmd.com have many links as well as prior courses on line • Link to Social Security Bluebook • www.ssa.gov/disability/professionals/bluebook/ • Contact your local professional relations unit for Disability Determination Services

19. Your response and questions • Questions • Comments • Criticisms