“Can I have time off work?” How I handle requests for extended leave of absence

Today we will discuss how I handle requests for an extended leave of absence as a psychiatric NP.

Welcome to post two! I’m so excited to see more people joining today! This one is going to be a doozy! But here we go… If you have been practicing as an NP (or PA – let’s include PAs here!) for any length of time, you have encountered it. A patient comes in for a first time appointment and as you go through the evaluation every question comes back to work.

“How have you been sleeping?” “Oh horrible, I’m so exhausted at work.”

“How is your concentration?” “Terrible, I can’t get anything done at work?”

“How’s your mood?” “Terrible, I can’t stand to be around my co-workers.”

You know what’s coming next. You get a lump in your throat as you attempt to finish the evaluation and the patient says, “Oh one more thing, can you fill out these forms for me? I need time off work.” AHHHHH!! You KNEW it was coming! You KNEW it! Nonetheless, the tension in the room mounts as you try to figure out what to do next…

There’s a couple of different scenarios that led to this moment. By the time the patient makes it to a psychiatric NP, it’s possible someone in primary care already saw them, gave them a few weeks off, and when they were not ready to return to work referred them to psychiatry for more intensive treatment. Or primary care referred them to psychiatry immediately. Or they have missed a lot of time at work for mental health symptoms and now they are seeking treatment for the first time since they have used up all of their sick leave and need to apply for FMLA and/or short term disability. Now the patient fully expects for their leave of absence (whether through FMLA or a short term disability claim) to be extended and for the time between their primary care referral and the time they made it to your office to be covered as well. WHAT?? Where in the world did they get this idea??

At this moment I am thinking SO MANY things. Why would you stop working prior to receiving this recommendation from a medical provider? How in the world would I be able to cover time off you missed before you were even my patient? WHY are we meeting for the first time and things are now so serious that your mental health concern is cause for “disability???”

You can say this sounds heartless. That’s okay. Once you have been faced with this situation 101 times you have to be start being a bit more objective. Don’t get me wrong, if an established patient needs medical leave, like REALLY needs medical leave, I am your number one advocate! If a new patient is truly ill enough to impair their ability to work, I’m here for you. If a patient needs time off work to seek more intensive treatment, I will absolutely go to bat for you. But let’s be honest… 95% or more of our patients seeking medical leave (at least in psychiatry or for psychiatric purposes) are not sick enough to merit taking an extended leave of absence from work.

So, what do I do next? First I have to shut down my personal feelings. My personal feelings are work is good for people. A busy and productive mind is a happy mind. I believe my patients need to be working, volunteering, doing something that gives them the opportunity to contribute to society (if at all possible) which will have a huge positive impact on their mental health. For this interaction I have to place these thoughts in the back of my mind.

Once I can shut down my personal feelings I start to EDUCATE. I have found education to be the savior in MANY difficult situations. I educate the patient on the purpose of FMLA and short term disability. I educate the patient on the process of applying and advise that MOST times the short term disability claims in mental health are denied so they may end up never getting reimbursed for their time off. I say, “Insurance companies approve or disapprove your time off, not your provider. I can make a recommendation, but ultimately it’s in the insurance company’s hands.” Then I dive into discussing the best way to treat their mental health concern (which is the whole reason they are in my office, right?). At this point, the patient believes the best way to treat their mental health concern is to take time off work. This thought has to be reframed and again we EDUCATE about what will REALLY help their mental health. We discuss medication, therapy, and more intensive treatment options. When I need to be VERY direct I say, “If your mental health concerns have become severe enough to merit a disability claim, then we also need to discuss inpatient treatment (or partial hospitalization treatment at the very least).” Treating a patient who is so severely mentally unstable that they cannot perform their job functions and need an extended leave of absence means that they are likely not a good candidate for traditional outpatient psychiatric services at this point in time. Outpatient treatment offers you a 15-20 minute visit with the NP/PA/MD biweekly or monthly and then weekly therapy (if a therapist is available, they can afford it, and/or their insurance will cover it). That is just not enough. If someone is seeking a leave of absence for medical reasons the person is likely having surgery, doing physical therapy, birthing a baby. They are doing something that requires their time and energy be invested in the healing process. Why should psychiatry be any different? Taking a leave of absence and dedicating only one hour a week (or less) to mental health treatment is simply not productive.

What happens next? Once I have given the patient all of this information the end result varies widely. If the patient was only seeking an extended leave of absence, they usually leave upset. If the patient is in need of help and ready to work toward recovery, I provide a list of partial hospitalization programs and my patient starts making calls that same day to start treatment. At the start of my career I had a VERY hard time saying no or delivering news people wouldn’t want to hear. So, on several occasions I gave in to patients who requested an extended leave of absence and let them refuse more intensive treatment. Do you know what happened? The patients met with me once every other week for the length of their time off, reported no change in their symptoms, and at the end of the leave of absence we were in no different shape than at the start. They requested another extension on their leave of absence over and over again. Most of the time these claims were denied and sadly once the leave of absence was over, so was the patients willingness to attend office visits. I quickly realized that telling the patient what they wanted to hear was not helping them at all. So, my methods changed. Once patients started engaging in partial hospitalization programming they raved about how beneficial it was and were more ready to return to work with new coping skills and a much better frame of mind. One patient even told me, “Everyone should have to go through this program when they start mental health treatment. It changed my life.” That’s when I realized that to really help people I might have to ruffle some feathers along the way.

So, now the patient has gone through treatment, they return to work, and they come back to you two weeks later and they are decompensating again? What then? It’s very important to decipher between a patient who has a mental illness that prevents them from working and one that dislikes their job. If a patient dislikes their job or their boss they won’t like the answer… find a new job.

What are your thoughts on handling short term disability claims in psychiatry or other specialties? How often are you faced with this? How do you handle it? Leave a comment below! I can’t wait to hear your thoughts! As always, thanks for joining!