Are You Prepared for a Disability?

It was late August last year and, following my usual half-day in the office on Saturday, I was looking forward to heading off to Rehoboth Beach, Del., for a few days of relaxation.

My husband and I arrived on Sunday, and the following morning set off on a bike ride along the boardwalk and down this quaint beach town's many side streets.

This pleasure trip turned to tragedy, though, when I blacked out and crashed to the ground.

When my husband didn't see me in his bike mirror he retraced his path and found me lying bleeding and unconscious on the ground, in the throes of a seizure. A passerby called an ambulance on a cell phone and I was rushed to the ER.

Learning to walk

A physician there took care of some sutures for a cut around my left eye and a neurosurgeon was brought in to diagnose the extent of my injuries. The diagnosis: a left temporal lobe contusion that caused a subarachnoid hemorrhage.

After the neurosurgeon performed a life-saving craniotomy and subsequent tracheotomy, I remained unconscious for eight days.

The etiology of the bike accident was and is still unknown. Tests have ruled out a myocardial infarction and an aneurysm. At 50, I have suffered from hypoglycemia for 29 years, but have no other medical conditions.

When I regained consciousness from this traumatic brain injury, the CCU nurse said that after I adjusted my glasses, my first words were, "I have patients tomorrow morning at 8:00."

But now, a year after the accident, I am still unable to provide care for my patients, and have had no choice but to sell my practice to the optometrist who filled in for me during my recovery.

My preliminary rehabilitation (I still suffer side effects of my brain injury) took five months and was a grueling journey. When I was transferred to a rehabilitation hospital, I could not sit up or walk. I had to relearn everything - how to lift a fork and glass, how to bend over to reach a pot in the kitchen cupboard, how to walk up and down stairs and shower. It wasn't until three weeks after the accident that I could walk unaided.

I have now regained functioning of numerous systems, but my vision and cognition still suffer the after-effects of my injury. I work on building muscle strength and body balance daily, and to this day, often walk with my head down to keep from falling. Shopping was and still is a chore. At first, the overload of visual and auditory stimuli made it unbearable to be in any store. I experienced dizziness and saw double.

At the end of January this year I was finally able to begin driving again, and went to the grocery store by myself. However, I still required help unloading my items onto the conveyor belt and carrying bags to and from the car.

I have had an extremely difficult time accepting the seriousness of the injury I suffered and the fact that it will have long-lasting effects on my lifestyle and daily functioning.

Still in recovery

And as you can imagine, this past year has also been a terrifying and stressful time for my husband, Phil, who spent long, arduous hours monitoring me lying in what seemed to be a lifeless state, entangled in bandages and tubes.

When I was released from the hospital, Phil had to cook dinner every night for several months, do all the shopping and paying of bills, and generally be on hand to help me with daily tasks like bathing.

As for my practice, Phil was responsible for keeping it functioning until a substitute optometrist could take over. (I have since sold the practice.)

A spouse will always bear the brunt of responsibility when his or her partner suffers a disability, but the burden doesn't have to be quite as large as the one I placed on Phil. Like many practitioners in the prime of my career, I had no emergency plan in place in the event I suffered a life-threatening injury or illness. A heart attack, stroke, unplanned surgery or traumatic brain injury can affect any practitioner at any age. Unlike chronic disease states which develop slowly and frequently with predictable stages, an acute, disabling event can occur in just a few minutes. It can alter your life personally and professionally for a few brief weeks or, as in my case, a lifetime.

Planning it out: stay open or close down temporarily?

As with any solo or group practitioner, who will cover the patient care becomes the primary question. Since most doctors are not on salary with paid sick leave, meeting income and expenses becomes a consideration. Office staff can reschedule non-acute patients for the first week.

Ideally, you will have designated a substitute practitioner ahead of time who can take over for you -  if only on a temporary basis. This gives your spouse or office manager time to find a long-term replacement if necessary.

It would be helpful to include in your emergency plan a list of contacts at local medical societies and board certification organizations who can help line up a covering physician.

Pay can be structured either on a per-hour rate, for doctors under contract, or as a percentage of gross or net for a long-term substitute.

Immediate concerns

A spouse or designated other should make a list of staff and their home phone numbers, as well as a list of suppliers and their phone and account numbers. Also include a list of office policies. He or she should have office keys and the alarm code.

The responsibilities for the spouse in and out of the office should be itemized. The office staff should also have a written plan outlining their responsibilities. Their role in integrating the substituting doctor should be outlined.

In my case, my husband told the staff that the clinic would remain open and to continue with their duties. Their hours were reduced as the substitute doctor was only working part-time. They, along with the substitute provider, were told to assess follow-up patient care by reviewing patient charts. Recalls for six- or 12-month follow-ups were printed and patients were notified that a different physician will be seeing them.

My staff told patients that I had had a terrible accident, offered some details, and said I was recuperating. They said that although they didn't yet have a date for my return, Dr. X was covering for me in my absence and gave his schedule. They also told patients a little background about the substitute's experience.

Effect on partners

Partners can share in the same feelings and concerns as a spouse or family member. He or she can feel overburdened to take on additional patient care and administrative work while the partner is disabled. Again, it takes a great burden off whoever is left to pick up the pieces of the practice if pertinent operational information is available in an organized, coherent list.

Maintaining patient loyalty

Maintaining patient loyalty is extremely crucial and vital to any practice's survival. Have staff tell patients that the doctor plans to return as soon as possible. Tell them, "Dr. X has provided care for you for many years and now, due to unfortunate circumstances, cannot do so temporarily. However, Dr. X wants to be able to provide you continuity of care and has hired a physician who is familiar with your case and will give you great care until she returns." I lost only a handful of patients due to my illness, and some patients simply postponed their annual visit.

Financial impact

There's no way around it, plan on a 50 percent revenue loss. The substitute provider simply will not have the same motivation to keep revenues high as the owner of the practice. For this reason, paying the practitioner a percentage of gross revenues may be more beneficial than straight salary. Staff members can't do much regarding revenue but they can help the covering physician with patient flow. In addition to the drop in revenues, my retirement plan contribution was severely curtailed.

To lessen the income loss, good disability insurance coverage is imperative. This includes both a business interruption policy and a personal coverage plan. A business interruption policy includes provisions for rent, utilities, staff salaries, insurances, legal and accounting fees, and all expenses incurred. Before deciding on the amount of coverage, include those expenses that occur monthly, quarterly and annually.

Note these policies do not traditionally cover a colleague's salary. A separate disability personal policy should be included in the coverage. This in essence will provide you with monthly income. Each insurance company has different policies.

Consider the waiting period for coverage to begin. Practitioners often choose 30 days for business interruption and 90 days for the personal plan. The extent of coverage varies between policies, with business interruption traditionally being for 12 months and personal policies until age 65. A careful consideration is partial disability and what the waiting period is, if, for example, you return to work and then must leave again within a few weeks. Do you need to wait another 90 days before coverage kicks in?

Barbara Anan is an optometrist and writer living in Washington, D.C.

This article originally appeared in the January/February 2006 issue of Physicians Practice.