Residual Functional Capacity Assessment for Gastrointestinal Hemorrhaging
What Is RFC?
When your gastrointestinal hemorrhaging is not severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process, the Social Security Administration will need to determine your residual functional capacity (RFC) to decide whether you are disabled at Step 4 and Step 5 of the Sequential Evaluation Process. RFC is a claimant’s ability to perform work-related activities. In other words, it is what you can still do despite your limitations. An RFC for physical impairments is expressed in terms of whether the Social Security Administration believes you can do heavy, medium, light, or sedentary work in spite of your impairments. The lower your RFC, the less the Social Security Administration believes you can do.
Assessing Impairment Caused by Gastrointestinal Hemorrhaging
The severity of anemia is gauged in severity by the hematocrit (Hct) of venous blood. A normal hematocrit (Hct) in women is about 38 – 44% and in men 42 – 48% at sea level. How anemia affects an individual’s exertional capacity depends on their overall health, their age, and whether the anemia is acute or chronic. In chronic anemia, the body has had more time to physiologically adjust—to the extent possible—to the decreased availability of red blood cells. Younger individuals can tolerate chronic anemia better than older people. In regard to overall health, improvement in anemia can make a big difference in the functional capacity of someone with heart or lung disease; by the same but reciprocal reasoning, it is clear that decreased oxygen delivery to the body’s tissues will worsen many kinds of impairments. Additionally, there is the question of bleeding risk and what kinds of activities would reasonably be prohibited on that basis—an issue the SSA adjudicator is very likely to overlook.
The medical literature can be misleading regarding the symptoms of anemia, because physicians’ orientation is usually clinical medicine rather than disability determination. For example, it is common for the assertion to be made that many patients do not have significant symptoms with hematocrits of 30% or even much lower. Such statements must be viewed with caution in the context of disability determination, because individuals with no symptoms during their usual sedentary daily activities or in their doctor’s office would be symptomatically limited by the exertional demands of medium or heavy work. One of the cardiac compensation responses to severe anemia is an increase in the rest heart rate and, obviously, that is going to affect exertional capacity. A young claimant can generally perform much more exertion than a middle-aged person with the same hematocrit, because their cardiovascular system can more effectively compensate. From an anemia standpoint alone, however, it is difficult to believe that most claimants could perform medium or heavy work with a hematocrit in the low 30% range—especially if they are older individuals.
There is no medical information on how much exertion a claimant can safely do in regard to bleeding risk with various impairments involving some kind of persisting anatomical abnormality associated with a prior bleeding episode. However, in the case of unoperated vascular malformations or esophageal varices it would appear prudent to avoid heavy lifting and carrying, even if there were no documented bleeding episodes and no anemia at the time of adjudication. If the vascular malformation is particularly likely to bleed due to location or size, or if there is a multiplicity of malformations, it is conceivable that a RFC could be as low as sedentary work even with a current normal hematocrit—in order to avoid the risk of bleeding. If there are recurrent bleeding episodes from any cause and the hematocrit is within a few percentage points of meet-level severity, it would seem reasonable that the RFC should be close to the listing—sedentary work. On the other hand, a claimant with the underlying cause of bleeding resolved, such as a healed gastric or peptic ulcer, operated tumor, or cessation of drugs that caused bleeding, would have no limitations. Medical judgment must be applied on a case-by-case basis. The greatest danger to the claimant is that the SSA adjudicator is unaware of the various issues that may be involved and make a medical determination only on the basis of the claimant’s current hematocrit. If challenged on the issue of safety with a particular RFC, the SSA’s only defense is that this issue is a matter of medical judgment in the absence of definitive studies (which no-one can do for obvious ethical reasons). However, that same reasoning means the SSA has no objective basis for defeating a reasonable and medically competent judgment that is different —such as that of the treating physician. Particularly if the claimant’s hematocrit is less than 35%, he or she should be asked about the previously discussed symptoms that are possible with anemia.