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Henry J. Roth

Abstract

Assessing medical causality requires a clear understanding and discussion of causal relationships, and definitions of impairment may have special meaning in a legal context beyond their usual meanings in medical communications. In addition to assessing cause and effect and medical possibility vs medical probability, evaluating physicians must understand and carefully use terminology such as aggravation or exacerbation that have specific definitions and uses. Documentation of aggravation or causation depends on the acquisition, review, and analysis of medical documentation, including medical office and hospital records; available past medical records; results of tests or diagnostic procedures; results of permanent occupational or environmental surveys; medical information showing that an alleged factor could have caused or contributed to the effect; and occupational documentation of an alleged exposure or cause. Pitfalls during the assessments include the patient's aging, natural inherent limitations, self-abuse, and psychosocial factors that individually or collectively may confound medical causality and apportionment assessment. The evaluating physician alone is responsible for apportioning these factors and must provide the medical basis for all conclusions and opinions. Previous impairment of an organ system may be subtracted from the current impairment rating, and the written analysis should address separately a divergence between changes in impairment and disability.

in AMA Guides® Newsletter
Henry J. Roth
and
Christopher R. Brigham

Abstract

This article (continued from the previous issue) discusses and clarifies 21 key principles for using the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fourth Edition. Tests of inconsistency are good but imperfect indicators of patients’ efforts, and if observations or test results are insufficient, the physician should explain the modified impairment assessment in writing. The AMA Guides includes rules for interpolating, measuring and rounding, and evaluating, and physicians should be familiar with them. In general, impairment percentages allow for pain that may accompany the impairing condition. If possible, the evaluator should remove a patient's protheses during evaluation. Physicians should consult the Combined Values Chart if the effects of treatment prevent adequate impairment management. A patient's decision to decline therapy for a permanent impairment should neither increase nor decrease the estimated impairment. The AMA strongly encourages use of the most recent of the AMA Guides. Impairment percentages derived according to AMA Guides criteria should not be used to make direct financial awards or direct estimates of disabilities. Combining, compared to adding, is a mathematical process to prevent estimating impairments greater than 100%, and the Combined Values Chart provides guidance for use. Divergent ratings should be matters of fact, not opinion.

in AMA Guides® Newsletter
Henry J. Roth
and
Christopher R. Brigham

Abstract

The AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides) Fourth Edition, is based on fundamental principles, particularly Chapter 1, Impairment Evaluations, Chapter 2, Records and Reports, and the Glossary. This article (continued in the next issue) discusses and clarifies 21 key principles for using the AMA Guides. For example, the AMA Guides applies only to permanent impairments, and impairment percentages are estimates, not precise determinations. All impairment ratings should be combined to express an impairment of the whole person. The AMA Guides establishes an evaluation process, and the medical rating itself is not the process or purpose addressed. An impairment estimate is simply a number and does not convey information about the effects of the impairment on the person's activities of daily living. A definition of normal requires nuanced evaluations in which physicians are asked to express opinions about the absence or presence of disability. Examiners should evaluate the patient's full range of possible active motion without the application of moderate pressure to the joint. Some patients with extremity pain or other symptoms may not have evidence of permanent impairment, and if the effects on different organ systems contribute to impairment, these estimates should be combined. [Continued in the March/April 1997 The Guides Newsletter]

in AMA Guides® Newsletter
Restricted access
Christopher R. Brigham
and
Henry J. Roth

Abstract

In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, apportionment refers to the “distribution or allocation of causation among multiple factors that caused or significantly contributed to the injury or disease and existing impairment,” and causation is the process of determining “an identifiable factor (eg, accident or exposure to hazards) that results in a medically identifiable condition.” Causality assessment requires a clear understanding and discussion of causal relationships; apportionment analysis refers to the extent to which factors may have contributed to a particular effect or impairment. A causal relationship requires three elements—a cause, an effect, and a specific relationship between them—the absence of any one of which disqualifies causality. Apportionment is an estimate of the degree to which each of various medically probable occupational or nonoccupational factors contributed to a particular impairment. The unique legal standards of compensability and apportionment vary by locality, and the apportionment of disability involves assessing the functional effects of different injuries over time. Evaluators should consider the effect of using the Combined Values Chart on the final assessment and must carefully distinguish factors that are combined vs those that are added or subtracted. A sidebar discusses important changes to the State of California's Workers’ Compensation.

in AMA Guides® Newsletter