A doctor can make or break a disability claim. If you read my post about the importance of medical records you will understand that without “good quality” medical records you simply cannot win your disability claim.
Now, let’s talk about an issue I come across very frequently and that it’s really important to bring it up.
I’m talking about claimants who have been treating with the same doctor for many years and how that can actually translate into “poor quality” medical records.
Introducing Dr. X
You love Dr. X. He’s been treating you for 10, 15, 20 years. He knows you. He knows all about your medical impairments over the years. Now you need to file for disability and you think: “Dr. X know’s everything about me. I’m all set!”
Unfortunately, it’s not always the case.
In fact, in my experience, the longer a doctor has been treating a patient the more complacent he will be about the treatment.
There are a few ways to interpret the statement above:
- Dr. X knows your medical file so much that he doesn’t even bother writing complete notes like most doctors do;
- Dr. X is very set in his ways and will not try a new treatment because has been around a while and thinks he knows everything;
- Dr. X and you have a silent agreement: He doesn’t have to go out of his way to treat you and you don’t ask too many questions. You just do what he says.
So let’s break these 3 statements down:
Dr. X knows you for years and years but his medical notes are very sparse
Why would Dr. X not write a lot of notes on your medical file?
Simple: If he has been treating you for many years he knows every detail about you. He remembers you and all the details of your treatment.
You see, most medical notes are not necessarily for the patient or anyone else to see (with a few exceptions). These notes are mostly used by the doctor to remember a particular patient’s treatment and diagnosis.
Can you imagine a doctor remembering information from every single patient he has? That would be nearly impossible. That’s why medical notes exist.
Now put yourself in his position. If you remember someone and their story do you really have to write it down?
No. Because you remember.
And that’s when problems can develop:
When a doctor knows so much about you and remembers every detail about your medical issues, his medical notes tend to be more sparse. Why?
Repeat after me: “it’s because he knows you“. He doesn’t need to read his notes to remember the details of your medical issues.
When a doctor knows you, he tends to jot down the bare minimum and only because there may be some minor changes to medications or a new symptom you are reporting.
And this translates into “poor quality” medical notes for those occasions when YOU really need them, i.e. when filing for disability.
What exactly does “poor quality” records mean?
It simply means that no one can tell by the content of the notes what is really going on in the mind of the doctor. The notes also fail to clearly indicate that your symptoms are severe enough to disable you.
You may see diagnosis (which we know are not enough to qualify you for disability), some information about medications and a little bit about your complaints. But very little about observations by the doctor and what he really “sees” during each consult (for more details about the quality of medical records please read my post about the importance of medical records).
Simply stated: Your doctor may know your medical file really well based on his memory but a judge cannot read your doctor’s mind. And whatever is NOT on paper it DOES NOT exist for the judge!
Your doctor may know and believe you are disabled but if he fails to write his thoughts down, then you have nothing to show to prove your disability.
Dr. X knows everything and will not try a different treatment
Every once in a while, I come across claimants who have a doctor who simply will not try anything new.
I’m not a doctor by any means. But it is not uncommon in my practice to know that a new treatment exists and learn that a claimant’s doctor never offered that treatment to his patient.
I sometimes wonder if the doctor is simply not “evolving” along with new science or is simply “too cocky” and thinks he knows everything.
In a case like that, it becomes obvious that the patient did not have all possible treatments available for his medical conditions. If so, how does this patient know he’s disabled if not all options were exhausted?
A judge is not a doctor either
But just like myself, he sees enough medical records every day. He is also familiar with most treatments available out there for the most common impairments appearing in front of him. If a judge sees that not all treatments options were exhausted, he will be less likely to award a claim.
There will always be a question in his mind: “what if this claimant tried this treatment and it worked?”
The medical records from this particular doctor will reflect this doctor’s “lack of care” (pun intended).
Which brings me to the next situation:
Dr. X and you have a silent agreement
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Some doctors are so busy with patients that they just don’t want or have time to go out of their way for a patient. And patients are so “trusty” of doctors that they think what a doctor says it’s the law. They follow their doctor blindly and without any questions.
This situation can be very damaging to a disability case.
A doctor who has no time for a patient is not doing any favors to that patient. A patient who follows a doctor blindly may be missing other available treatment that could improve his/her life.
The sad part is when a claimant comes to my office and I see that the doctor didn’t even offer the most basic testing. Or worse, the claimant has a medical condition that clearly requires a specialist and yet the doctor never offered a referral.
And I say it’s sad because 1) the claimant is filing for disability without proper medical testing for a clear diagnosis, and 2) the claimant never saw a specialist who could have offered better treatment with the possibility of a cure.
Medical records in this scenario will reveal that it’s clearly too early to file the claim because not all treatment have been explored and it is unclear if a claimant is really disabled without proper treatment.
So is it time to get rid of Dr. X?
Maybe. Maybe not. That will depend on a lot of things.
- Is he the only doctor treating you? If so, I would suggest asking for a referral to a specialist if you think your treatment reached a plateau.
- Are you able to get a second opinion just to see if a “fresh” set of eyes can find some other treatment for your condition? Maybe your doctor has known you for so long that he just spends more time chatting than actually looking at your chart.
- If you started asking questions about your treatment, would your doctor listen to you or would he just brush it aside? A lot of doctors “raise their feathers” if you try to dig a little deeper or when you ask why you should take a particular medication. If this is the reaction, please refer back to item 2 above.
4. What does your gut instinct tell you about your doctor? You may like him, but is he really doing everything he could? I once had a doctor who was a sweetheart and he loved to chat. But the actual examination would last only 5 minutes compared to 25 minutes of menial conversation. It was nice having a doctor who spent time with me. But how much of that time was really dedicated to my treatment?
5. Since you know Dr. X for a long time, are you able to ask him to improve his medical notes? would he be willing to do so? Now, If he agrees then this will certainly benefit you.
6. If he’s not going to change his notes, is he at least willing to testify at your disability hearing? This may help overcome his “sparsely” written medical records. And the doctor doesn’t even have to be present at the hearing. He can appear by telephone.
I know it’s hard to make changes in your life, especially when it comes to finding a good doctor. But if you are looking to win your disability claim, you need to pay attention to your treatment. Otherwise, it will all be a waste of time. We don’t want that.
I want you to win!
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