Negotiating with Terrorists

What’s an employer to do if it wants to avoid hiring new employees with psychiatric or substance abuse problems that might interfere with performance, lead to increased liability and raise costs for accommodation and sick leave? I have performed independent psychiatric examinations of employees for public sector employers like law enforcement agencies, but many private sector employers want to minimize costs to maximize profits by utilizing a cheaper alternative than hiring an independent examiner.

Enter Comprehensive Health Services (CHSi), whose Web site suggests they will "help maintain a healthier, more stable and productive workforce." I learned about this company when a patient applying for a job asked me to provide him with a copy of his medical record. CHSi, apparently finding my records inadequate for their needs, demanded that I fill out two "forms."

The word "form" has become a euphemism in medicine. Strictly speaking forms collect factual information, like names, addresses and phone numbers, but most so-called forms that patients ask me to "just fill out -- oh, and sign," include questions designed to elicit my professional opinion, often deviously disguised with words like "believe" or "think." In reality CHSi avoids the cost of a legitimate forensic opinion by finding a sucker, the treating professional, to do the work for free, oblivious to the adverse impact on the treater's relationship with the patient, in this case by holding the patient's job, and the patient, hostage, hoping to coerce me into essentially working for CHSi. Think negotiating with terrorists.

When I perform a fitness for duty or other forensic evaluation I owe little or no duty to the subject, only to my client who pays me. There is no role conflict. My clinical work, in contrast, implies duty only to the patient. If I mix these roles, my ability to treat the patient and my credibility as a forensic expert both suffer. How can a professional maintain objectivity and professional ethics when the patient depends on them for getting a job or money?

In the case noted above CHSi not only wants a new evaluation, which will serve only their interests and those of their client employer, but they want the prospective hire to pay for it, further blurring boundaries.

How do CHSi and similar companies get away with this? As Pogo said, "We have met the enemy, and he is us." We enable this exploitation every time we minimize our action by "just" signing the "form," giving away our expertise to a third party, and damaging, sometimes irreparably, our relationship with the patient. We can only stop these companies by refusing to participate. My recommendations:

  • Avoid providing opinions about patients. Your duty to diagnose and treat the patient is sacred.
  • Only provide opinions to a third party paying you to make the assessment.
  • Never treat a patient you have assessed for a third party.
  • Never lie in filling out such a form or attestation.
  • Assume responsibility only for providing the best treatment, never for getting your patient money or a job.
  • Report suspected misconduct by licensed professionals working for companies like CHSi to licensing boards.
  • Provide only the medical record.
  • Tell only what happened in the past.
  • If you feel compelled to respond to an opinion question, record only what you have or have not recommend to the patient. For example, instead of "In my opinion the patient is fit for duty." say, "I have not recommended that the patient stop working."
  • Refuse to complete any such request for information or opinion unless the third party has provided a phone number you can call to clarify questions.
  • Never do research for the third party. If they want information about a condition or treatment, direct them to behavenet.com!
  • Consider discharging the patient if you belileve the request has already damaged your relationship with the patient.

Do not let companies like CHSi, employers or government agencies tempt you to hastily "fill out the form" with little or no thought or competence in making such determinations, especially if you lack the requisite expertise. If you lie, the CHSi's of the world will swear to it, and no one's interests will be served, except those of their stockholders.

Don't negotiate with terrorists holding your patient hostage.

More on this case: Ask a Silly Question

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