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- Author or Editor: Charles N Brooks x
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Abstract
Independent medical evaluations (IMEs) are widely—and often, inappropriately—used in the claims management process. An IME includes a review of all pertinent medical records; an interview (history) and physical examination; a review of laboratory results and test results; and an edited and signed written report. The primary value of an IME is the report, because a credible medical opinion obtained at the right time can provide information necessary to initiate appropriate action in claims management, both for insurers, who will have a solid basis for acceptance or denial of a claim, and for claimant attorneys, who may use the evaluation to gain acceptance of a claim. A list of common problems in IMEs shows issues about which evaluators should be particularly careful, including questions of use, timing, choice of examiner, adequacy of questions asked and information received, expectations not defined, and framing the evaluation in a negative manner. From a client perspective, IMEs can be improved in several ways, and physicians should understand these opportunities for improving the quality, effectiveness, and value of evaluations. Because referral letters sometimes fail to ask detailed, focused, and probing questions, examiners who have any doubt about the conduct or objectives of the IME should contact the referral source. Detailed checklists and specifications can help ensure completeness and compliance. The article includes a box with definitions of frequently used IME terminology.
Abstract
Workers’ compensation and personal injury claims often become embroiled in debates about the cause of the clinical presentation. When the primary claim involves an extremity, affected individuals sometimes report subsequent symptoms in the contralateral, previously “normal” limb and often attribute its onset to overuse while favoring the initially involved extremity; such an overuse hypothesis seems plausible, and perhaps intuitively obvious, to some. The concept that favoring one upper limb can result in injury to or illness in the other is not based on scientific evidence and instead is an unsupportable myth. Determining relationships between risk factors or exposures and medical conditions is a complex process that is outlined in the Guides to the Evaluation of Disease and Injury Causation (Causation). A search on PubMed and MEDLARS using the key phrases “opposite uninjured arm” and “uninjured arm” returned only six relevant articles, and the authors report that claims of serious or persisting painful syndromes in the arm or hand opposite the injured one are seldom adequately supported by clinical evidence. Similarly, the literature does not support “favoring” as a reasonable cause for development of symptoms in the contralateral shoulder or elbow. Epidemiological studies can provide general information regarding risk; this information must be filtered by specific steps to assess causal association for a disorder and determine if the injury is work related. Findings then can be applied to the specific individual.
Abstract
In most cases of shoulder injury at work, causation analysis is not clear-cut and requires detailed, thoughtful, and time-consuming causation analysis; traditionally, physicians have approached this in a cursory manner, often presenting their findings as an opinion. An established method of causation analysis using six steps is outlined in the American College of Occupational and Environmental Medicine Guidelines and in the AMA Guides to the Evaluation of Disease and Injury Causation, Second Edition, as follows: 1) collect evidence of disease; 2) collect epidemiological data; 3) collect evidence of exposure; 4) collect other relevant factors; 5) evaluate the validity of the evidence; and 6) write a report with evaluation and conclusions. Evaluators also should recognize that thresholds for causation vary by state and are based on specific statutes or case law. Three cases illustrate evidence-based causation analysis using the six steps and illustrate how examiners can form well-founded opinions about whether a given condition is work related, nonoccupational, or some combination of these. An evaluator's causal conclusions should be rational, should be consistent with the facts of the individual case and medical literature, and should cite pertinent references. The opinion should be stated “to a reasonable degree of medical probability,” on a “more-probable-than-not” basis, or using a suitable phrase that meets the legal threshold in the applicable jurisdiction.
