Book Review

Disability Evaluation

N Engl J Med 1996; 335:1246October 17, 1996

Article

Disability Evaluation
By Stephen L. Demeter, Gunnar B.J. Andersson, and George M. Smith. 638 pp., illustrated. St. Louis, Mosby, 1996. $75. ISBN: 0-8151-2400-7

A century ago, any worker who could no longer maintain gainful employment because of injury or illness had little recourse but to charity. Many could only take to the streets, where 15 percent of the population of the industrial cities eked out a living until death ended their struggle. Fear of this fate drove the development of the insurance industry and the labor movement. It also nurtured political movements such as Marxism and socialism. The Prussian government under Otto von Bismarck outlawed the socialists. But wary of further alienating labor, Bismarck created a “welfare monarchy” as a trade-off.

A century later, the tenets Bismarck established are so entrenched that they seem to be common sense. It is held that if the illness causing the inability to work arose out of and in the course of employment, then workers' compensation insurance should pay for all care until the worker reaches the point of maximal medical improvement and indemnify the worker against all loss of wages during the healing phase and subsequently, if the worker suffers any residual effects. However, if the illness causing work incapacity is not a consequence of a workplace injury, then social-security schemes that are far less generous come into play, providing some medical care and some safeguards against the specter of poverty if the illness precludes any substantial gainful employment.

The administration of such an indemnity scheme would have been straightforward if Bismarck had been willing to believe the worker who asserted that he or she was incapacitated. Bismarck was not so trusting — and neither has been the government of any industrialized nation since. Who is really disabled? Who is lying? Prussian medicine offered a solution to the conundrum, a reductionistic solution that is also part of today's common sense. The argument derives from the diagnostic algorithm with which we are all comfortable: patients present symptoms, and physicians deduce the underlying disease. Prussian medicine asserted the converse: the incapacity to work is a predictable consequence of the underlying disease, or “impairment.” Thus was born impairment-based determination of disability. If the claimant lacks sufficient pathoanatomy, he or she will be determined to lack credibility.

The United States adopted workers' compensation insurance state by state during the first half of the 20th century. Social-security disability schemes were more of a problem. Congress was convinced that the medical determination of disability was feasible; medicine was not so convinced. Congress carried the day in 1956. Shortly thereafter, the American Medical Association began producing its Guides to the Evaluation of Permanent Impairment and the Social Security Administration its “Listing of Impairments.”

Today, disability determination is an industry. Hundreds of thousands of Social Security claimants submit to “contracted examinations” by physicians they have never seen before. Probably even greater numbers of workers' compensation claimants are subjected to “independent medical examinations,” become embroiled in litigation, and are assigned to “work hardening” and “rehabilitation” programs. So many physicians are involved in this industry that they have created an affinity group, the American Academy of Disability Evaluating Physicians. And there has been a call for a treatise that expands on and explains the American Medical Association Guides, rendering them more accessible, comprehensible, and readily applicable.

Disability Evaluation is that treatise, published under the imprimatur of the American Medical Association. For any physician, lawyer, or allied health professional who has reason to use the Guides or even the “Listing” or has the inclination to participate in the disability-determination process, this treatise is a useful resource. Such readers will learn how to measure impairments, organ system by organ system, and prepare reports. They will understand their role in the legal arena. They will hear from physicians who operate “pain clinics” and “work hardening” and “rehabilitation” programs why theirs are particularly valuable resources for the worker whose claim is contested. They will learn from ergonomists that they must define the task in order to appreciate whether the impairment is limiting. They can even learn from surgeons the point at which empirical interventions offer some special benefit to such claimants. They will learn to “do what is expected” of them. The industry that is “disability evaluation” finally has its manifesto.

As for me, I saw in this treatise the condemnation of the contemporary disability-evaluation enterprise. Its sophism is nearly perfect and, at some level, is recognized by many of the authors. The book is peppered with disclaimers. The fact is that basing disability determination on impairment, short of end-stage disease, is not scientifically tenable. The fact is that ergonomic factors predict disability poorly if at all. The fact is that no rehabilitation program has been shown to be reliably effective, let alone cost effective, in returning workers' compensation claimants with back or arm pain to the work force. The fact is that the scheme is no match for such impairmentless illnesses as chronic pain, psychiatric illness, and somatoform disorders — which may be iatrogenic. In fact, for me, this treatise serves as a clarion call to abandon impairment-based disability determination and initiate public debate on alternative schemes to provide comfort for the people among us who are too ill to do so for themselves.

Nortin M. Hadler, M.D.
University of North Carolina School of Medicine, Chapel Hill, NC 27599-7280

Citing Articles (1)

Citing Articles

1. 1

   Ray Bellamy. (1997) Compensation Neurosis: Financial Reward for Illness as Nocebo. Clinical Orthopaedics and Related Research 336, 94-106
   CrossRef