Management of a patient with chronic lung disease does not end with its treatment. Those with chronic pulmonary disorders need additional assistance and guidance on issues related to respiratory impairment, including causation or attribution; apportionment; eligibility for, and access to, various compensation systems; workplace modifications or removal from the workplace; and vocational and other forms of rehabilitation. Unfortunately, most physicians avoid providing these services, often with disastrous socioeconomic and medical consequences for the patient.
Multiple reasons underlie the general attitude of physician reluctance in addressing impairment. These include a fear and poor understanding of the legal system as it relates to work-related diseases, pervasive confusion about various compensation systems, a mistaken notion that those who seek impairment assistance are usually malingerers, lack of training in impairment evaluation, and a desire to avoid uncompensated efforts in the context of an already burdensome clinical schedule. This chapter provides an understanding of this complex, but ignored, area in clinical pulmonary medicine.
This field of impairment and disability evaluation bridges medicine and law; hence, its terminology, drawn from both fields, can be confusing. The terms, impairment and disability, are often used interchangeably, but they are not synonymous. In 1980, the World Health Organization issued a statement defining impairment as, “any loss or abnormality of psychological, physiologic, or anatomical structure or function,” and disability as, “any restriction or lack, resulting from impairment, of ability to perform an activity within the range considered normal for a human being.”1 The resulting social and occupational disadvantage is designated as handicap.
For a patient with chronic lung disease, the goal of respiratory impairment evaluation is objective measurement of the extent of loss of function, primarily through application of pulmonary function or exercise testing. The physician plays a key role in impairment evaluation. On the other hand, the impact of the respiratory impairment on a person’s ability to perform day-to-day activities is called disability, which is typically determined through application of administrative and legal instruments by experts in these areas. The experts not only rely upon the evaluation of impairment provided by the physician, but also take into consideration other social and legal issues, as well as the energy requirements of the occupation. Impairment may occur without disability, and disability may occur without measurable impairment. Furthermore, two individuals with exactly the same respiratory impairment may suffer differing impacts on their lives, and consequently, have different levels of disability.
Respiratory impairment may be temporary or permanent. In contrast to temporary impairment, permanent impairment is not expected to improve with time or treatment. Disability may be partial or total. Total disability implies that an individual is unable to perform any work of the kind that he or she has the skills and qualifications to perform. Partial disability implies that an individual is able to perform some, but not all, of the work.