This was not going to be easy. Rodolfo had returned to the community clinic in South L.A. where I work. He wanted another signature to extend his disability for a few more months. The problem? He was too healthy.
Rodolfo had first come to see me six months before. His diabetes was out of control. His sugars were running four times the normal limit; his vision was too blurry for him to read; he was exhausted; and his feet burned from injury to his nerves. Through lifestyle modification on his part and a little help from me in the form of free medication and education, I could promise him better health. Think of it as an opportunity, I told him.
Rodolfo was unemployed at the time and unable to imagine holding any type of job in the condition he was in. The period off work would afford him the chance to focus on his health. And the strategy succeeded. Now, six months later, his sugars were well controlled, and he felt much better.
Presumably I had learned something about Social Security disability insurance in medical school or residency, but it was a topic so peripheral to my practice of medicine that it barely registered. Even when I began working in L.A., six years into my professional career, I didn’t worry so much about the disability applications I signed. I was confident that some other ill-defined “disability doctor” would be reviewing the case to determine whether the degree of stated impairment qualified as disability.
Slowly, as I put my signature on form after form, it dawned on me how integral my input was to the outcome. One time I signed an application based on the report of a Mexican specialist about a patient’s vertigo. I wasn’t convinced, but there were no specific tests that I could do to either prove or disprove the diagnosis. I didn’t authorize extended disability—just enough time for the patient to get to an American ENT to verify the diagnosis. The benefits agent who called me seemed skeptical, but she accepted my determination with little discussion.
Without insurance, however, my patient still had not received the specialty appointment through the overburdened county system more than three months later. I couldn’t help feeling I was doing a disservice to the public health mission as I signed my patient’s renewal application while we continued to do nothing but wait.
I don’t relish my role as disability arbiter. I want to make my patients better, not parse out how sick they are. What’s more, I don’t feel like anyone ever taught me the rules. Fortunately, at my clinic, we have a medical–legal partnership, and we work side by side with lawyers. They instructed me in the elements of a good disability letter, and they taught me about “The Grids,” an arcane system that categorizes hundreds of symptoms and assigns each a disability value.
The impact of health care reform, passed by Congress just seven months ago, has been swift and dramatic. Overnight, the focus has shifted from the quantity of health care provided to the quality. It has reached every level of community care in South L.A., from the Department of Health Services to the Medicaid insurance plans to the individual clinics. We are all rushing to reorganize our services to ensure that we strive not only to hit the health outcomes about which we care so deeply, but to prove that we have met them. We always felt that case managers who would keep track of specialist referrals and other programs were important, but now we will be rewarded for the care coordination they provide. It used to feel that the financial bottom line distracted from these goals, but the new incentives feel right on target.
Now, as I sign one disability form after another, I turn a more critical eye both to this system and my own role within it. The intent of the disability system is clear—in the event of debilitating illness, people will have financial security. When healthy, they return to the workforce. Clearly, there are many who have legitimate and sometimes even permanent debilities. But just as it is difficult to know if sick is sick enough, the line between better and healthy is also blurry. When disability enters the equation, along with being the doctor, I am also the boss. Unfortunately, the job is to be sick.
At some point, I stopped signing Rodolfo’s disability continuation, and it has been a long time since I have seen him. He either doesn’t need me to sign his forms or knows that I won’t. Either way, I am not helping him monitor his diabetes. As we re-envision health care and its delivery in America, I dream that we will recreate the disability system in its wake. I want to find a way to pay for health and recovery, not debilitation.
Ellen Rothman, HMS ’98, practices at a community health center in Los Angeles.
