Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. 

-World Health Organization 1948

 

Disabilities is an umbrella term, covering impairments, activity limitations, and participation restrictions...Overcoming the difficulties faced by people with disabilities requires interventions to remove environmental and social barriers.

-World Health Organization

 

 

I precept family medicine residents and, not infrequently, have noticed that a resident may be seeing a patient younger than 65 who has Medicare as their primary insurance.  So I will then ask the resident "what is this patient's disability?" and often, they do not know because they haven't thought to ask.

 

This week I heard a provocative piece on NPR entitled "Unfit for Work: The startling rise of disability in America."  The piece got me thinking about our role in assessing patients for disability and, more importantly, wondering how we can best help our patients with disabilities to experience health as defined by the World Health Organization (see quote above).  You can read or listen to the NPR story here:  http://apps.npr.org/unfit-for-work

 

As with any intervention, the Social Security Disability Insurance program has both positive and negative effects.  While this story focused primarily on the negative effects and limitations of our disability system, it forced me to think about my role in contributing to the complete physical, mental and social well-being of my patients with disabilities.  I believe that illness can threaten one's personhood (what makes each of us unique) and result in suffering.  Our role, as physicians, is to promote healing to restore, maintain or grow those important attributes that make us who we are.

 

One point to consider is the difference between diagnosis, illness, and disability.  It may be obvious, but diagnosis is what we are responsible for making.  Illness is the way a diagnosis negatively impacts one's life and therefore one's personhood and often results in suffering. Disability can be a positive and sometimes wonderful aspect of one's identity, another dimension – much as race, religion, gender, and geographic origin – are all part of what makes us who we are.  People with disabilities could certainly name the negatives and limitations, but they could also tell you the many gifts the experience of disability has brought.  On the other hand, by linking a medical condition to an inability to work to financial benefits and a label of "disability," the federal government casts this aspect of personhood in a negative light and creates incentives to focus only on the limiting aspects of disability.   

 

Where I see our disability system succeeding is in helping to lift people out of financial destitution and placing them solidly in poverty with just enough money to get by.  Where it fails is in supporting a person through a healing process so that, despite physical or emotional limitations, individuals may experience complete physical, mental and social well-being.  I recognize that physicians only play a limited role in how this system works, but I have a hunch that perhaps we could do better to support our patients through the healing process.  

 

I'd like to hear from you about your thoughts on this and what role we as individual physicians, or the NHMS, should play in improving this system.  Next week, I'll revisit the issue of transparency in health care bringing together the thoughts you shared with me over the past few weeks.

 

Please email and questions or comments to president@nhms.org or post a comment below.

 

Comments

Wow! lower the bar a little more and none of us will have to work. Fabulous. I see SO MANY patients that start our conversation with, "can I get on disability with this?" When I tell them that there is a good chance that I can fix the problem so that they won't be "disabled" they sometimes fire back with, "why would I want to do that?" If the "disability" is not readily apparent to this resident...it should often be telling you something. There are those who through no fault of their own require outside assistance for a fairly devastating problem. Please tax me and use the money to help them get along. IMHO that bar is way too low and just like welfare, this is now a desireable lifestyle option for many and I would like to see it curtailed. My opinion.

The NPR piece was very disturbing as it highlighted the failures of a system that is moving people from employement to a shadow system of disability payments. The statement that stayed with me was that people enter the system and "either stay on it until 65 or death" There doesn't appear to be any real effort to help people reenter the workforce. The whole process that was detailed, from the role of physicians, lawyers, and an industry that has developed to identify people on Medicaid and move them into the Social Security Disbility System so that states can save money seems corrupted and certainly not in the person's or the country's best interest. Just my take on it. By the way, the whole story can be heard on This American Life as a podcast or from their website.