Collecting Disability Benefits: Tips for Physicians Experiencing Burnout

The number of physicians filing disability claims for “burnout” has increased significantly during the past decade. Estimates of burnout in the physician workforce range from zero to 80.5 percent, depending on how burnout is defined and measured.(1) A frequently cited study(2) puts the estimate at about 50 percent. Physician burnout is widely recognized as having serious adverse consequences for clinicians, patients, healthcare organizations, and society as a whole.

As originally conceived by psychologist Christina Maslach, burnout is characterized by emotional exhaustion, depersonalization (i.e., cynicism), and decreased personal efficacy in response to a stressful workplace.(3) Predisposing factors in medical settings include high caseloads, long hours, cumbersome and time-consuming EHR systems, role conflict and ambiguity, toxic leaders, perceived unfairness, and organizational changes due to business buyouts, downsizing, mergers, and acquisitions.

A deeper look into burnout portrays physicians as the victims of moral injury.(4-6) At the root of their distress is a broken healthcare system that prevents them from providing high-quality care and healing. Essentially, the system thwarts the efforts of physicians to do right by their patients. Doctors feel powerless, as if the trust they placed in the medical profession has not been reciprocated or, worse yet, has been rejected. They feel unable to practice medicine the way they were taught and in ways consistent with their professional values.

The only solution to dealing with this untenable situation is to leave work. It’s no wonder some physicians turn to short-term disability for assistance; they see a temporary leave of absence from work as a means to restore wellness and combat burnout.

Case reviews have found, however, that “[p]hysicians are very likely to have their claim denied if they cite ‘burnout’ as their disabling condition. Usually insurance companies play down the distressing experience of the physician and hold that the physician is either stressed out or does not like his/her job; or maybe is planning to leave the practice and is not actually disabled. Professional apathy alone is not considered a disabling medical condition and a disability insurance company will not accept ‘burnout’ as a disabling condition that is compensable.”(7)

My previous experience as a disability claims reviewer for a large insurance company validates the statement that short-term disability claims, including claims submitted by physicians, are rarely approved for burnout.

Based on insight gained through my experience working in the industry, I offer these recommendations for physicians (and their caregivers), with the goal of easing the emotional and administrative burden of collecting disability benefits in the event they experience burnout.

1. Document a DSM-5 diagnosis. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), does not recognize “burnout” as a psychiatric diagnosis. Burnout is viewed as an occupational, rather than a mental, problem, driven largely by factors in the work environment such as excess or unrealistic job demands coupled with insufficient resources, lack of control, and inadequate support. Many of the symptoms of burnout, however, overlap with major depressive disorder (MDD), and MDD should be diagnosed instead of burnout when the DSM-5 criteria for MDD are met (see Table 1).

Other psychiatric conditions commonly associated with burnout include post-traumatic stress disorder, anxiety disorders, and substance use disorders. A DSM-5 psychiatric disorder should always be indicated on a claim form in lieu of “burnout.”

2. Specify the nature of the symptoms. Underlying psychiatric symptoms caused by burnout — those that comprise the mental health diagnosis — must be present and well-documented. Attorney Mark F. Seltzer remarks, “When suffering from burnout, physicians may experience a myriad of health problems, cognitive difficulties, insomnia, depression, anxiety, substance use disorders, fatigue, difficulty with personal relationships, and disruptive and performance-related issues at work.”(8) The severity, intensity, and duration of psychiatric symptoms must be capable of being substantiated via a medical chart review.

3. Document impairments and limitations. One of the reasons it is difficult to “prove” disability is because work typically is one of the last areas of functioning to be affected by mental disorders.(9) Yet mental health impairments can and do cause observable deficits at work, usually referred to as functional deficits or performance deficits.

Impairments and resulting limitations must be clearly delineated in the medical record in order to establish a short-term (or long-term) disability. From the perspective of a claims reviewer, there should be no doubt about the correlation between psychiatric symptoms and functional deficits. Impairments and limitations are the bridge between symptoms and deficits.

4. Consider activities of daily living. It would be expected that a psychiatric disorder severe enough to preclude all work activities would also cause notable difficulties in most or all other life activities — activities of daily living (ADLs) and instrumental activities of daily living (IADLs). A psychiatric disorder likely would not be severe enough to preclude work and yet have little or no impact on ADLs/IADLs and social functioning. Impaired ADLs/IADLs may signal impairment in other spheres of life and affect global functioning.

5. Put “stress” in perspective. Stress is ubiquitous and by itself confirms neither burnout nor disability. Attorney Derek R. Funk observes, “In our [firm’s] experience, when physicians use the term ‘burnout’ on claim forms (prior to our involvement), insurance companies seek to trivialize and downplay what the physician is going through, and often maintain that the physician is just ‘stressed’ or ‘hates his/her job,’ has secondary motivations for leaving practice, and is not actually disabled.”(10)

Likewise, the AMA Guides™ to the Evaluation of Work Ability and Return to Work state: “There is no job that has been described in the medical literature as ‘free of stress,’ and there is no case report of an individual whose personal life has always been free of stress.”(11, p. 269)

6. Separate confounding issues. A bad fit between the physician and a workplace does not constitute a mental health disability. The position of the AMA Guides is that “complaints that derive from issues like conflicts with a supervisor, other types of job dissatisfaction, a wish to take time off from work for various personal reasons, etc., must be separated from symptoms due to mental illness.”(11, p. 418)

Many of these types of problems are psychosocial in nature and are not the equivalent of burnout. In addition, virtually all physicians have caregiving responsibilities outside of work, e.g., child, spouse, parent, friend or others with major health problems. These additional non-work responsibilities are frequently conflated with disability claims.

7. Expect to be denied. In 2016, approximately 15 percent of short-term disability claims and one-third of long-term disability claims were denied after initial review.(12) Although it is not known how the rejection rate for individuals with mental illnesses compares with the overall rate — let alone physicians claiming mental disability — mentally ill individuals can have a particularly difficult time obtaining disability benefits.

Inadequate or missing information in disability claim files are common reasons for denials. In addition, treatment variability in psychiatric patients makes it difficult to predict the outcome of therapy and fitness to return to work. Thus, insurance reviewers are likely to be conservative in their rulings lest they inherit a case with no guideposts or framework for determining a reasonable return-to-work date.

8. Appeal adverse decisions. Neil Young’s song “Don’t Be Denied” (and the documentary by the same name) implores us to persist beyond personal hardships. And so it is that appealing insurance claim denials can be complicated, frustrating, and confusing — but many initial denials are successfully overturned on appeal.

The physician and treating provider(s) may submit additional information to the insurance company to consider during an appeal. The same documentation standards apply, i.e., submit objective and detailed mental status and behavioral observations that support findings of a functional deficit. The tone of progress notes, evaluations, letters, and other correspondence should be professional, without hyperbole, rancor, or ranting. Information that is inconsistent, contradictory, or not representative of the clinical facts and findings may cast doubt on the issue of genuine, severe psychopathology and cause insurance companies to question the veracity of the claim.

9. Know your insurer’s disability policy. It behooves physicians to know whether their policies include diagnostic and preexisting condition limitations, “own occupation” or “own specialty” clauses, and other exclusions that are non-starters to filing a claim. Specifically, are mental health and substance use disorders covered? Must treatment be contingent on seeing a certain type of provider, e.g., a licensed or doctorate-level psychologist or psychiatrist? And must treatment be ongoing to be eligible for benefits?

Knowing the terms of one’s disability policy can help a physician plan accordingly and prevent wasted time filing a claim that may be denied for administrative, as opposed to clinical, reasons. It is not uncommon for physicians covered by group disability insurance policies to also have private insurance policies tailored to their unique needs and concerns.

10. Seek legal counsel. Physicians applying for disability due to burnout need to be prepared to contest insurance companies seeking to trivialize and downplay the situation. Insurance companies are vigilant in protecting their own interests, which often means not paying claims. Physicians therefore need to be even more vigilant in protecting their own interests by seeking experienced legal counsel to assist them in submitting their claims for benefits.

A recent Hastings Center Report concluded: “The medical community should not be left to grapple with the phenomenon of physician burnout alone. The law has a significant role to play in addressing the problem.”(13) Just as the law routinely safeguards the health of workers such as pilots and air traffic controllers in safety-critical professions, so too should it protect physician’s whose jobs are every bit as safety-critical.

Discussion

Taking time off from work is considered a natural remedy for physician burnout. Of course, other targeted therapies such as counseling, mindfulness training, stress management, and systems-based interventions also may be useful.

Following a leave of absence, many physicians return to work invigorated and optimistic, with a more positive outlook on their jobs. Other physicians use the time off to make personal and lifestyle adjustments and return to work in a different capacity, perhaps in a new or modified job in the same or different organization.

Sylvie Stacy, MD, MPH, a preventive medicine physician and author of the popular blog “Look for Zebras” (https://lookforzebras.com ), advocates for nonclinical jobs for burned-out physicians as an alternative to practice, but not for those who act out of frustration. Rather, a career switch to management works best for “recovered” physicians whose career goals have changed in a meaningful way and who genuinely seek a nonclinical job.(14)

Unfortunately, many physicians face significant challenges accessing their short-term disability policies for the purpose of seeking compensatory relief during time off from work. Physicians applying for short-term disability benefits may be subjected to intense personal scrutiny by insurance company representatives, including review of their medical records and possibly the use of surveillance and other investigative measures that strip away personal privacy.

If burnout has affected a doctor’s performance to the extent that his or her medical staff privileges have been restricted or suspended, there may be a duty to report such restrictions to state medical licensing boards, even if the physician takes a voluntary, as opposed to forced, leave from work.

Many experts have pointed out that what appears to be a mutually healthy decision and course of action for burned-out or impaired physicians and their healthcare systems may be viewed by state medical licensing boards as grounds for an investigation. The arduous task of filing for disability insurance, compounded by the possible detrimental effect of a state inquiry into a physician’s ability to practice medicine or renew or retain his or her medical license, deters many physicians from seeking treatment for burnout and other mental health problems.

Given the high prevalence of burnout, all physicians need to be educated about available resources and treatment options, especially the value of short-term disability benefits. There is no reason licensing boards and disability insurance carriers can’t revise, where necessary and appropriate, their questions on applications to ensure that they are not discouraging physicians from seeking needed treatment.

While investigation tactics employed by insurance companies and medical licensing boards are not necessarily conducted in bad faith, legal guidance is most appropriate to prevent untoward outcomes for physicians who choose to access their disability benefits.

References

1. Rotenstein LS, Torre M, Ramos MA, et al. Prevalence of Burnout Among Physicians: A Systematic Review. JAMA. 2018;320:1131–50.

2. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in Burnout and Satisfaction with Work-Life Balance in Physicians and General US Working Population Between 2011 and 2014. Mayo Clin Proc. 2015;90:1600–13.

3. Maslach C, Schaufeli WB, Leiter MP. Job Burnout. Annu Rev Psychol. 2001;52:397–422.

4. Dean W, Talbot SG, Caplan A. Clarifying the Language of Clinician Distress. JAMA. 2020;323(10):923–24.

5. Dzeng E, Wachter RM. Ethics in Conflict: Moral Distress as a Root Cause of Burnout. J Gen Intern Med. 2020;35(2):409–11.

6. Ofri D. The Covenant. Acad Med. 2019;94(11):1646–48.

7. MOS Medical Record Reviews. Can Physicians Collect Disability Benefits for “Burnout?” MOS Medical Record Review. December 24, 2018. www.mosmedicalrecordreview.com/blog/can-physicians-collect-disability-benefits-for-burnout .

8. Seltzer MF. Disability Insurance as a Tool for Restoring Physician Wellness. Physician’s Weekly. August 29, 2018. www.physiciansweekly.com/disability-insurance .

9. Gold LH, Shulman DW. Evaluating Mental Health Disability in the Workplace. New York, NY: Springer; 2009.

10. Funk DR. Can You Collect Disability Benefits for Burnout? HCP Live. August 24, 2018. www.hcplive.com/view/can-you-collect-disability-benefits-for-burnout .

11. Talmage JB, Melhorn JM, Hyman MH. AMA Guides™ to the Evaluation of Work Ability and Return to Work, Second Edition. Chicago: American Medical Association; 2011.

12. American Council of Life Insurers. Claims Procedure for Plans Providing Disability Benefits; Extension of Applicability Date (RIN 1210-AB39). December 11, 2017. Accessible at www.dol.gov/sites/default/files/ebsa/laws-and-regulations/rules-and-regulations/public-comments/1210-AB39-2/00186.pdf .

13. Hoffman S. Physician Burnout Calls for Legal Intervention. Hastings Cent Rep. 2019; 49(6):8–9.

14. Stacy S. 50 Nonclinical Careers for Physicians. Tampa, FL: American Association for Physician Leadership; 2020.