Consultative exams are ordered by DDS adjudicators when they want to know more about your condition and the limitations it causes. Often this is because your disability application or medical records were incomplete, outdated, or contained conflicting information. There’s nothing nefarious about a CE request, despite conspiracy theories to the contrary; it’s an opportunity to bolster your case. Once it’s part of your record, your lawyer can use it during appeals if your claim is denied.
These appointments aren’t made with your input; you’re told where to go and when to be there. (Rescheduling, while possible, risks delaying a decision by several months.) The letters I received about mine stressed that you aren’t charged for the exams or any x-rays, blood work or other testing that’s ordered, and that transportation costs are sometimes reimbursable. None of the work is performed by government employees; it’s outsourced to experts with no financial interest in whether you’re approved or denied.
With that — and yesterday’s exams — out of the way, I won’t pretend it was a pleasant experience. Being sent to these is like being told “Prove it,” which makes sense for many claims but irks me for obvious reasons. The waiting room of the medical suite to which I’d been dispatched was dimly lit and grubby; it looked like it hadn’t been updated in 40 years. Because another practice usually operates from these quarters, white copy paper was taped over the door signs and nameplates. On it, the names of temporary staffers were scrawled in blue ballpoint pen ink.
If you’ve ever been in a drugstore where all the merchandise is locked up, the waiting room had that vibe. The end tables and magazine rack were stripped of periodicals; there was nothing to look at but Veterans Crisis Line fliers and a stack of business cards bearing the hotline’s phone number. The VA outsources its disability exams now and a few men in the waiting room endorsed their veteran status, either verbally or through hats and shirts that referenced their service. Several of my fellow waiters were prone to histrionics, yelping as they sat down or stood up, and the women staffing an open check-in counter window ignored their cries.
My first appointment was with an internist in her late fifties who spoke softly, with faint remnants of a South Asian accent. She reviewed my medical history and, like many non-gastroenterologists, needed a j-pouch refresher. The physical exam began with a request to lift my arms until they were directly in front of me, and I watched as she registered the tremor in my left hand and murmured to herself, jotting a note. Next came arm-raising in different directions, hopping on one foot, walking on tiptoes and heels — everything but riding a unicycle.
Lastly, she produced a small wooden board with shoelaces, a zipper, and a small piece of fabric with buttons, and asked me to perform each task. I’d last completed such an obstacle course in kindergarten, using a board that also contained a lock. She paid minimal attention to my progress; she was finishing her notes. At no point during our visit did I have any clue what she was thinking. When it was over I returned to the waiting room, where a distraught middle-aged woman who spoke minimal English alternately ranted to a disinterested companion and wept; her appointment hadn’t gone well.
Twenty minutes later, in the psychologist’s office, I related to her dismay, though my eyes remained dry. A preposterously tall young man introduced himself as “Dr. So-and-So,” not specifying whether he was a psychiatrist or psychologist. Upon spotting the DSM-5 on his desk, I was confident he was the latter, which an internet search later confirmed.* He wore a self-serious beard that was probably only cultivated for pompous stroking, along with a Lacoste gingham Oxford shirt that retails for $140.** While he set to work analyzing me, I did the same of him and wasn’t keen on the results.
However he came to possess such a shirt (maybe it was a gift or a snazzy counterfeit), it was a status symbol that stuck out like a sore thumb in surroundings so desolate.^ Weighed with his imperious demeanor during the exam, one had to consider the unpalatable possibility that he enjoys the power he holds over disability applicants, many of whom are financially desperate. But that’s a sinister thought and I’m inclined to go with Hanlon’s razor and assume he’s simply aloof and beleaguered.
“We’re here today to discuss your mental health history,” he began in a somber tone more befitting a conversation about inoperable cancer than a chat about forgetting a mortgage payment. Despite this introduction, he made few attempts to actually discuss anything. Mostly he theatrically took notes and double-checked them, uttering the occasional ‘Hmm’ as he surveyed his work. When he reached the end of a page, he wet his index finger with his tongue, then peeled the sheet off the stack in front of him and placed it facedown on a second stack to its side.
Our first awkward moment, and only protracted exchange, came almost immediately, when I replied “I didn’t realize I had a mental health history–“
“You have a history of depression, anxiety, and possible forgetfulness,” he interrupted. “You’re prescribed an antidepressant.”
“It’s prescribed by my neurologist for Parkinson’s symptoms,” I said, intuiting that I was about to get cut off again. What I wanted to clarify, since my lawyer explained last week that the examiners wouldn’t know much about my history, was that my medical records contain no mental health diagnoses and I’m not under the care of a psychiatrist. The MDS currently considers those issues to be normal byproducts of YOPD that she’s comfortable treating in the same way she treats my dystonia and sleep problems.
“Prescribed for depression,” he interjected.
“My understanding is the dose of Zoloft we’ve given for Parkinson’s is so low it would be like a placebo for regular depression. But it helps with the agitation and anxiety and low mood that are common with Parkinson’s.” When I relayed this to Crankenstein later, she confirmed it’s correct, but he was visibly skeptical.
“Tell me about your ‘low mood,'” he said in a patronizing way meant to convey the term was interchangeable with depression.
“It’s complicated,” I answered. “It could be chemical or situational. Levodopa helped first and Zoloft handled the rest.”
“Did you have feelings of worthlessness?”
“Yes. Parkinson’s messes with your self-confidence.”
“Did you self-harm or want to end your life?”
“No.”
“How is your mood today?”
“Not great, but that’s because someone close to me just died.”
He didn’t react, facially or verbally, and moved on to more questions and additional interruptions. It was a brief appointment that concluded with a short cognitive assessment quiz that has no utility for someone potentially in the early stages of memory decline.
“Then why does he use it?” I asked Crankenstein that evening.
“Maybe to weed out malingerers.”
In that context, which was so obvious I felt dumb for having missed it, I suddenly had more empathy for Dr. Lacoste and the expensive little crocodile on his shirt. One can only imagine how much bullshit he encounters in a typical week of such work, and how often he’s probably lied to and verbally abused by the people he examines. That doesn’t excuse the beard or performative note-taking, but I’ll grant him some aloofness — without it, he might get eaten alive.
* No self-respecting (attending) psychiatrist refers to the DSM too often, much less in front of patients; it’s information they should already know. It would be like a cardiologist clutching Myocardial Infarctions for Dummies while investigating a possible heart attack.
** Let the record show I have nothing against gingham Oxfords and even own a couple myself, but you have to be careful with gingham or history might remember you unkindly, like Aaron Schock, the first person I always think of when reminded of that fabric (or of Downton Abbey).
^ These aren’t just dreary experiences for applicants, it’s also bottom of the barrel work for physicians who do it as anything but moonlighting. I assume that’s also true of psychologists, who will encounter a high number of applicants with complex mental health histories and behavioral issues that make normal interactions difficult. Assembly-line assessment of such cases would be difficult to do well and is probably quite draining.