New Research Shows Doctors Listen to Your Symptoms for Only 11 Seconds Before Interrupting. Three Things You Can Do to Lessen The Risk of Damage to Your Treatment, and To Your Disability Claim.

New Research Shows Doctors Listen to Your Symptoms for Only 11 Seconds Before Interrupting. Three Things You Can Do to Lessen The Risk of Damage to Your Treatment, and To Your Disability Claim.

Sometimes your Disability case is lost at the doctors office. Your doctor will interrupt you while you are telling her what the problem is – you need to make a list and “talk doctor.”  Speak up! 

Social Security Disability Looks to Medical Records to Assess Disability. In the evaluation of disability, medical records are the primary source of information. For Social Security disability claims, your application is forwarded to the Disability Determination Service in your state, and we request your medical records and send them to your disability examiner there. The medical records reviewed by the disability examiner and the medical examiner at the Disability Determination Service contain the information that Social Security will rely on to find you able to work, or find you disabled.

Why? For one thing, to establish disability under Social Security regulations you need to be unable to sustain full time work for over a full year. In your medical records Social Security is looking to see and consider your illnesses that your doctor diagnosed, and the symptoms you reported during your medical visits. Of special concern are your symptoms, your pains, the intensity of your pains, the duration of your pains, and how much they could limit you in daily life not just for one day or a month, but over an extended period of time, over a year or more. Here is the central question: Could these limitations as shown in the regular unfolding of your medical records over a period of time explain to a decision maker that you are indeed incapable of working at a simple job during the period covered by the medical records?

It’s not What You Say, It’s What Your Doctor Says. Many people expect that what they say to a decision maker about their pain and the limitations they have due to their illness will be the primary data to be considered in assessing whether they are found disabled and entitled to the monthly income benefit. Not true. The reason for this is two-fold, first the decision maker needs to decide if what you say is true, or are you exaggerating just to secure the monthly disability income. Second, the decision maker knows it is very hard to remember things accurately as they unfolded over a long period of time. 

Your statements about how you feel and how your illness limits you can be considered highly useful to establish your limitations on the day that you make the statement, but less useful when you speak about how you felt, your pain, and how you were limited by your symptoms 6 months ago, or 18 months ago.

Your Doctor is Very Busy.  Your Doctor Has to Enter Your Visit in A Computer Screen.                                                                                           

All this puts into ​perspective a true weakness in the evaluation of disability by Social Security, and generally in the medical care system in our country right now. Your doctor is in an environment that puts many demands on her, including record keeping, billing, meetings, continuing education, etc. Compared to years ago your doctor has less time to see you. In medical care terms this is called  “visit duration” and it used to be longer. Besides that, your doctor now has a big computer screen in the examining room to compete with you for his attention. The development of Electronic  Medical Records systems has great potential to improve record keeping and quality of care. However, there are downsides to everything, and with the entry of Electronic Medical Records, the medical interview is under pressure. Recording the facts from the medical visit and exam by typing the visit into several fields in the database on the computer screen would likely require the doctor to look at the computer screen (“computer facing”) instead of you (“patient facing”), and when she is not looking at you while you are speaking there is great opportunity for misunderstanding and miscommunication.

doctors officeWhy is that important? The doctor may not learn why you came to see her, and may not learn what you have to report by way of symptoms, pains and limitations. If that is true, either because the doctor has less time to see you, or is distracted by the presence of the computer screen or by the demands on him to type his notes of the visit, your “agenda” – the reason why you came to see the doctor, and your symptoms, and your questions, may not be addressed during the visit because it was never elicited by the doctor. In short, if she is rushed or distracted, or not good at the medical interview, your pains, your limitations may not show up in the medical record during a period of time in which you actually suffered from specific pains and symptoms that were relevant to your medical care and which prevented you from sustaining full time employment.

Social Security Disability Evaluation Assumes the Doctor’s Medical Interview Elicited Your Concerns 100% of the Time. This is a big problem for determination of disability since the prevailing logic of disability analysis is to infer a lack of symptoms and lack of limitations during a period covered by medical records that fail to document the existence of the symptoms and limitations. From the perspective of disability analysis, the medical interview is assumed to have been highly successful and therefor the report of the medical interview (your medical records) is considered highly reliable as a source for determining the existence or non-existence of disabling pain and other medical limitations.

This bears repeating or restating – when Social Security looks over your medical record, they are looking to see that the symptoms and limitations that you say prevent you from sustaining full time work are “backed up” by having been recorded by the doctor as a result of your conversation with the doctor in the medical interview, and by the medical treatment plan, and by objective testing by the doctor as needed for your care. When the symptom or limitation is not mentioned by the doctor, it could be assumed by the disability evaluator that for the period of time covered by the visit, you did not have that symptom or limitation at all, even if it is mentioned in the record of the prior visit and in the record of the subsequent visit. In this way, sometimes, the disability evaluators put more emphasis on the medical interview than it can sustain.

During the Medical Interview the Doctor Actually Elicits the Patient’s Concerns ONLY 36% of the Time.  A Mayo Clinic study published this summer (June, 2018) reports that during the medical interviews studied, the doctor was able to elicit the patient’s agenda 36% of the time, meaning that the doctor did not elicit the patient’s agenda 64% of the time. How does this happen? Primary care physicians were able to elicit the patient’s agenda 50% of the time, while specialists elicited the patient’s agenda 20% of the time. Wow!

In the study, Eliciting the Patient's Agenda - Secondary Analysis of Recorded Clinical Encounters the authors looked back at prior studies of medical interviews with an eye to assessing the degree to which the doctor was able to obtain from the patient the patient’s full spectrum of concerns. The study technique was to acquire access to a volume of recorded medical interviews, and then randomly choose 112 medical interviews (25% audio only, 75% video with audio) for evaluation by two reviewers working independently. 

medical checklistA pattern is shown in these recorded interviews. The doctor asks for the patient’s concerns but does not wait for the patient to finish their initial statement. Before the patient is finished, the doctor interrupts the patient - usually after 11 seconds! Really? What gets lost in the shuffle? According to the literature, sometimes, the most embarrassing details are left by the patient for the end (“late arising concerns”), and sometimes they are never reached during the interview creating missed opportunities for understanding and treatment as well as for substantiation of pain and limitations. There is a problem in medical care, in that the doctor is re-directing the patient’s initial description of their problem so early in the visit that the patient’s true concern is sometimes (how often?) never learned by the doctor. 

In order to receive the best medical care, and knowing that the medical interview is not always well done, what can you do? 

1. Make a List. 

Before your next visit, and for every appointment, make a list of your most pressing concerns and how you will describe these to the doctor. Write out the list.

2. Prioritize Your List

Re-shuffle your written list so that the big concerns are first.  When you are with the doctor talk about your top priority item first. Then go on to the second. 

3. Talk "Doctor"

The doctor is interested in details that show severity and intensity, don’t be vague, be descriptive. Your list should not only be in writing; it also needs to be in the language of “Talking Doctor” so you could just read it to her if she lets you. 

In the list you prepare in advance of your appointment try to describe your symptoms and pain in a way that makes it easier for the doctor to document your visit and saves her time. You can use a number to show severity or frequency of a symptom, and when you do that, when you provide a number, you are providing useful information. How does this condition or this symptom affect you in daily living?   Write out how long, how frequent, at what level.  Making your list at this level of detail prepares you to share with your doctor what your doctor needs to understand your situation and to provide you with the care that is most appropriate to your medical condition.

Use this detailed level of reporting to let the doctor understand if the symptoms are getting worse or getting better from appointment to appointment. 

Good Luck in Your Medical Interview! Be understanding when the doctor interrupts you at the beginning when you are stating your concerns. He is trying to serve you as best he can. And she often has a good reason to clarify or question you as to what you mean. But make sure you get back on track, by using your list and redirecting the conversation so the doctor hears from you what you prepared to say are your full spectrum of concerns for today’s appointment.

John L. Keefe
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Founding Attorney, Massachusetts Social Security Disability Lawyer