Tuesday, July 14, 2015

"My dad says I'm disabled"

In my last post, I mentioned how I discovered a few things I had started writing before I had this blog. The following is something I started to write after my experience as a part-time disability examination provider for a national company. It wasn't an opportunity that I particularly enjoyed, but with a mountain of debt to repay right out of residency, I decided to give it a try.
“My dad says I’m disabled”
      Room number 2 was the one. It was worth coming in 15 minutes early just to grab that spot. With 12 hours of monotony from 22 patients getting disability evaluations, the view from that room (and the extra income) made this day worthwhile. In between patients, I would place my palms on the one way panoramic window to channel the warmth generated by the Arizona sun shining down on the black facade of this nondescript office building.  From the 10th floor, I took full advantage of my peripheral vision by taking in the seemingly endless hills, mountains and blue skies. Such mental escapes were fleeting and constantly interrupted by patients trying to make a case to qualify for government assistance.
      I always took the time to review the charts the night before. It allowed me to be more efficient and objective the day of the exam. Whatever skepticism I had about each patient’s claim, I would try not to bring it to the office. I constantly reminded myself that it was my job to make an honest assessment of their medical conditions.  It was up to the government to ultimately determine if they qualified for disability payments. Most of the patients had chronic debilitating illnesses and I knew no matter what I wrote in in my assessment, they would probably qualify.
        When I read Jaina’s file the night before, I felt disappointed but also grateful. I couldn't believe a 20 year old with only depression and obesity would want to and try to qualify for disability. But I also realized this would be an easy visit that I could work through quickly and make up the time spent on more complicated patients. If the day became too long or frustrating, I would try to convince myself that I was performing a public service by helping determine if tax payer dollars should be used to support these patients.
      When I actually saw Jaina my skepticism was unfortunately confirmed. She walked in and sat next to me without any difficulty. My physical exam revealed nothing despite her assertion that knee and back pain limited her capability to work. My conversation with her had clues that her depression is what really limited her. She had a morose look to her face and struggled making eye contact. She was diagnosed by her primary care physician but had poor follow-up with him. She also hadn’t been referred to any mental health services which made me think if her depression was better managed, it wouldn’t be “disabling.” I asked a series of questions in terms of her abilities to do a variety of menial tasks and her answers indicated she could do everything. With each question she must have sensed my increasing skepticism towards her disability claim. At one point she looked away and welled up with tears. I asked her if she was okay when she muttered “I know I can do that stuff, but my dad says I’m disabled.” I paused, unsure what to say. I wanted to delve further but I was running out of time as the proverbial walls started coming up around her. Her answers after that confession was curt and she kept directing me back to her back and knee pain. I eventually had to complete the visit and send her on her way. I felt troubled by what she had just said. I felt even more unsettled thinking about all the things I would never see or understand about Jaina’s life that led to our meeting that day.
In retrospect, as I learned more about medicine and our health care system many things became clearer. I continue to believe she really was clinically depressed. In our perversely broken healthcare system, she probably had difficulty accessing primary care services.  She probably had limited access to mental health services especially ones that could be tailored to patients with specific cultural or language needs. Every day as I continue to see the critical role family plays in both good and bad health, I keep thinking about the injustice Jaina’s father had done to her. A 20 year old physically capable girl should be able to dream big and pursue happiness. Instead, it appeared that her father traded in her self-esteem and hope in exchange for an opportunity to get a few hundred dollars every month from the government. Conversely, I wondered what was going on with the father and his own struggles in our society that would make him take his own daughter down this path.
              It took me only a few minutes after reading her chart to figure out that the odds were against her to qualify for disability. It has taken me years of experience and a single moment to reflect to believe that the odds are against her for a chance at anything at all in this life. 


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