Social Security Sets Standards Of Medical Proof For Pain
You can tell by looking at your patient and her history that there is no way she could make it through an 8-hour work day, even in a sedentary occupation. Her pain would not allow it. You firmly believe she is genuinely disabled. How do you tell the Social Security (SS) people that?
Doctors need to know what kind of medical evidence SS requires to prove disability, especially from disabling pain or other “subjective” symptoms. Judges and courts give special significance to the opinions of treating doctors, when their opinions are properly based in medical findings. This article explains SS Rulings adopted in 1996 on these matters, some drawn from Oregon cases.
As a preliminary matter, a person claiming SS disability must have a physical or mental impairment or impairments which significantly limit the person’s physical or mental ability to do basic work activities and which will continue for 12 consecutive months or more.
Symptoms such as pain, fatigue, shortness of breath, weakness, or nervousness must first be established by objective medical evidence, that is, signs and laboratory findings which could be expected to produce such symptoms. However, the medical evidence does not need to prove the severity of the symptoms the patient claims to be experiencing, since patients’ pain tolerances and experiences vary.
If the symptoms impose functional limitations having more than a minimal effect on the ability to do basic work activities, then the impairment is regarded as -severe” even if the medical evidence does not establish that the impairment is severe. The claim may then move on to the next stage in the evaluation process.
However, since a symptom alone is not a “medically determinable impairment,” medical signs or laboratory findings showing an objective medical abnormality will be needed later to warrant a “disabled” determination. A “medical sign” is any symptom indicative of an anatomical, physiological or psychological ‘abnormality’ shown by medically acceptable diagnostic techniques.
Once a medical sign or laboratory finding is in evidence, the patient’s complaints about the intensity and persistence of the symptoms must be considered along with all other evidence. Thus, once there is an objective medical basis for pain, the patient’s “subjective” complaints take on greater evidentiary significance. Your chart notes, as well as the testimony of lay witnesses, may corroborate the patient’s testimony.
As treating physician, your opinion (as we said in an article in our Fall 1996 issue) is legally accorded “controlling weight” – that is, the judge/court is legally required to follow it in deciding the outcome of the case, if certain conditions are met: 1) if your opinion is well-supported by medically acceptable clinical and laboratory diagnostic techniques; and 2) it is “not inconsistent” with the other substantial evidence.
One key factor is that you have clearly explained the significance of the clinical signs and laboratory findings as they relate your patient’s disabling symptoms.
If there is inconsistent or opposing evidence, your opinion as treating doctor is still given deference and is likely to be adopted, as long as it is well supported.
Let’s consider more closely exactly what the judge will be expecting from you.
To be regarded as “medically acceptable,” your diagnostic techniques must be in accordance with the standards generally accepted within the medical community as appropriate, to establish the existence and severity of your patient’s impairment (examples: SED rate, MRI, x-rays, and possibly trigger points).
To be “well-supported” by these diagnostic techniques does not mean that your opinion has to be fully supported by this evidence.
Being “not inconsistent” with other substantial evidence does not mean that all the other evidence has to support or even be consistent with your evidence, as long as no other evidence contradicts or conflicts with your opinion.
A contradiction or inconsistency may exist, for example, if your opinion on how limited your patient is in performing work-related activities conflicts with other medical opinions, or even lay testimony about what your patient is doing. These, or an inconsistent interpretation of how your clinical signs and laboratory findings relate to diagnoses and prognoses, may require that you provide additional evidence defending or explaining your opinion (or rebutting or reconciling the apparent inconsistencies).
So, please remember that the legal system needs more from you than simply, “In my medical opinion, John Smith is unable to work.” A detailed opinion from you for your truly impaired patient may mean the difference between his/her being able to obtain Medicare or being left without coverage..
This article was prepared by Arthur W. Stevens, III