Well, good morning, everybody, and welcome to Session 212, the Independent Medical Examination. My name is Doug Martin, and in addition to being an occupational medicine doctor that practices in Sioux City, Iowa, I'm also honored to be ACOM's incoming president. So welcome, everybody, to the session this morning. We're going to go over some of the foundational things about independent medical examination, sort of the nuts and bolts of how an IME is done, how it's scheduled, and I'm sorry, these lights are just, like, incredibly bright, so it's taking me a little bit of a difficulty time here trying to get used to them. But the hybrid meeting that we're having today is challenging, even more challenging if you're the only speaker. So I have a computer up here that I'm trying to watch for questions and so forth that people put through on the chat that are virtual participants, and we do have four microphones available, so I'd ask you, if you do have a question, to come to the microphone because the actual presentation is being recorded as well, and we want to make sure that we get everything captured. So some of the things that we have to get out of the way, of course, you know, it's important whenever you do containing education to make sure disclosures are known. I told you that I'm AECOM's President-Elect. I also serve as the AMA Guides Editorial Panel Co-Chair. For those of you who don't know what that is, the AMA has decided to update the AMA Guides to the Evaluation of Permanent Impairment 6th Edition and put that in a digital format that will have continuous updating on a year after year after year basis. If you want more information on that, I'll talk to you later about that. I am a former President of the American Academy of Disability Evaluating Physicians. I was involved in reviewing the AMA Guides 5th Edition calculator reviewer product. I was also a 6th Edition reviewer. I've previously taught IME Principles for the International Academy of Independent Medical Evaluators. I currently serve as a HOD member to the AMA for the Iowa Medical Society, former past President of the Iowa Academy of Family Physicians, and I also teach AMA Guides course for AECOM which I did just this past Friday. So enough about that. Other disclosures. I do have a book that I wrote and it's an interesting story as to how this actually came about. There was in 2015 at this particular meeting a vendor from Springer who just so happened to walk past the back of the room when I was giving this same session and afterwards she called me and said, would you like to write a book about what you talked about? And I said, hell no. I don't have time to do that. And I was very resistant at the time because in my mind I thought that this was more like a CME oriented kind of a thing and I was never thinking that this would turn into a book. I went to AOHC the year after, did the same thing. Just so happened the same person was there and they decided to sit into the whole session. Anyway, to make a long story short, after getting weekly phone calls and weekly emails for about three months I finally caved. And I said, okay, fine. I'm going to go ahead and do this so that you quit calling me and quit badgering me. So it's out there. It's available I think on all of the typical outlets and so forth. I do get a royalty. It's not much. Everything that I make actually goes to my wife's Haiti mission organization, timeforhaiti.org if you want to look up and see what they do. So I don't take any money from this and pocket it. It's just one of those things that I like to do. Here's my contact information. I'd like to think that I'm fairly user-friendly, so if you have questions about anything, email, give me a call. I'll try to get back to you as soon as I possibly can. So let's dive into the world of independent medical examinations. When we think about IMEs, there are three basic types. There are workers' comp, independent exams, personal injury, and then I think sometimes the ones that we have a tendency to forget about, those that are oriented towards the long-term disability aspect of things. So in the workers' compensation arena, you may be asked things like, please conduct an IME to figure out an impairment rating. They may ask you questions about return to work and what you think about that. Very commonly you'll be asked questions about causation. Obviously this is key in the workers' compensation world because the folks that, you know, insure folks and companies that oversee the work comp benefit system obviously don't want to be paying for things that's not re-rated to work, so we make sure that we put those things in the right venue. And then they may be asking you about treatment recommendations as well, if there's some controversy or conflict about what should we actually be doing for the individual that is injured. In the world of personal injury, frequently what you'll encounter are motor vehicle accidents. That's by far the most common personal injury independent exam that's conducted, at least in the United States. And questions that arise behind that are things like extent of injury, you know, a person has an automobile accident, they claim that they have condition X, Y, and Z. Okay, fine, if that is indeed true, what is the effect of X, Y, Z on their ability to maintain employment, does it impact their activities of daily living, does it impact hobbies and basically how has that impacted their life? On the long-term disability aspect, there are several different ways that you can get involved in that. One is with respect to personal disability policies. Folks that apply for long-term disability because of significant life events, oftentimes there's a question as to whether or not that particular condition or problem is significant enough to meet the policy's definition of what disability actually is. And these get to be rather interesting. Oftentimes they deal with what we call the somewhat controversial diagnoses, things like fibromyalgia, multiple chemical sensitivities, and these types of things. Social security examinations, I actually put under this particular label of long-term disability. Now, you might say that the social security comprehensive examination is not technically an independent medical examination, but it's kind of along the same lines. You're evaluating a person that's not your patient. You're asked specific questions with regards to their capabilities. Can they lift? Can they carry? Can they walk? Those types of things. So it is something that's important to know. And by the way, in the social security world, there's an extreme need for comprehensive examiners. So I always tell people that if you're kind of new to the IME world, this is one of those arenas that you might want to explore initially just to kind of see if it's something that you like. Maybe you'll like it. Great. You can go on and do other things. Maybe you don't like it, and that's okay. At least you've gone through and experienced it. And it's a relatively non-controversial system. With regards to social security comprehensive examinations, there's not a lot of legal involvement, so you won't be spending a lot of time answering letters or being called to depositions and those sorts of things. And then there are VA evaluations, which I also put under this particular heading or topping of long-term disability. Completely different disability system, unlike anything else that you will encounter. Again, oftentimes not necessarily thought of as an independent examination, but it is because you're evaluating a service-connected disability claim for an individual that typically is not your patient. So those are kind of the three systems. Now, what I'm going to do for you this morning is I'm going to go through and explain to you what I consider the four C's of the foundational sort of makeup of how an independent medical examination should be conducted. And I don't have any particular references here for you. This is something that I just made up in my mind, but I think it makes sense when you think of it in terms as far as how you look at this. Obviously, the critical part of this is creating a quality medical report. And you'll hear me talk about this over and over and over about how critical it is to make sure that your report is very high quality. The reason for that is that a lot of the stakeholders that are involved in the processes where your independent medical examination report is going to be used may not know anything about you individually. They may not know anything about your typical practice. The only impression that they will have about who you are and whether or not you're a good doctor or a bad doctor is going to be based upon that written report. Now, we can all say that, well, you know, is that fair? Does that make sense? But in the reality of the way things work, that's how it is. All right. So what are these four C's? The first one is clarification of purpose. The second is complete preparation. The third is content. And the fourth is communication. Now what do we mean by these things? Okay. As far as clarification of purpose is concerned, this is some of the preliminary work that you need to do before you actually do the examination. It's basically doing your homework so that you can prepare yourself to do the best possible job that you can. What are those things? Well, the first thing that's very important is, is that you should verify the purpose of the evaluation with the requesting party and ask the question, what does the requester want? Now, you might think that that's a simple thing, but I will tell you in reality that there are many times that you will receive requests for independent examinations and the requesting party may not necessarily have a real good handle on what it is and what information that they actually need. Okay. When they send you a letter that requests the independent examination, oftentimes you will get these letters and you'll sit there and you'll scratch your head and you'll say, wow, this doesn't exactly seem very clear. I wonder what's going on. That's what we mean by understanding and clarifying what the requester wants. Some other things that are very important, verification of the mechanical aspects of the appointment. Appointment mechanics. Okay. Fine. They call your office. They set up an appointment for an individual. It's got a specific date. It's got a specific time. Do you as the independent medical examiner want that person actually at your office sooner than that to either fill out paperwork, fill out various different information forms, those types of things? That's the type of thing that we're talking about as far as mechanical aspects are concerned. The other thing that's important is to review the report standard with the requester. This is particularly important in doing workers' compensation independent medical examinations because this changes depending upon which jurisdiction that you're involved with. There are some states that are very rigid about how they want the independent medical examination report to be written. Some of them have specific requirements about things that have to be in there, that have to be in certain sections, and have to be addressed in certain ways. So you have to understand what these things are. As I always like to say, you have to understand the rules of the game if you're going to play them. Okay. So it becomes very important. And if you're not familiar with it, call your state workers' compensation agency and make sure you understand what those requirements are. Other things to pay attention to would be the question that is sort of underlying the whole process. Is this a determination of employability, meaning is the focus here on return to work and pretty much everybody has agreed to that? Or is the focus here on disability? Everybody's kind of made the decision that the person's never going to go back to work. So what is the process that's involved here? Is it a request for, like, what's going to be the long-term lifetime benefits? Is this person going to need lifetime needs for treatments X, Y, and Z? Those types of things. It's always important, I think, to make sure that a confirmation letter is sent. And a confirmation letter, I think, should be sent to both the individual that you're examining and also to the requesting party or the stakeholder that asked for your service. Now, those are two different kinds of confirmation letters. The one that's sent to the individual that wants your services is going to confirm the place and the time and the purpose for the examination. It's also going to talk a little bit about no-show issues. This is an important concept. Usually independent medical examinations are lengthy appointments, usually a minimum of an hour. Sometimes they can go up to three or four hours, depending upon the complexity of the situation. You've already blocked off a lot of part of your professional time to do this. You need to have some type of compensation if the person doesn't show up. I mean, that's just part of a smart business model. Now, I'm not going to sit here and tell you exactly what to do with that because there are a lot of changes based upon your geography as far as the supply and demand and all those other types of things that play into that. But you should have some sort of a policy that deals with no-show issues and what that's going to mean as far as payment. And then there may be some other payment issues. What happens if the person shows up late to the appointment? Think about rules that you might have on that. In my scenario, I have what's called a 20-minute rule. If the person shows up more than 20 minutes after the scheduled appointment, that's considered a no-show. I put that policy in this confirmation letter so that there's no confusion. There's no arguments about, well, you know, you didn't really tell us that this is what was going to happen and, you know, those kinds of things. So think about all those things and make sure that you verify that with the individual requesting party. The other thing that's important, though, on these confirmation letters is to also make sure you sent that to the individual that's going to be examined. Why is that? Don't rely on the insurance carrier or the attorney or somebody that has set up the evaluation for you to do that, okay? Now most of the time they will, but what sending a confirmation letter from your office does is it just reinforces and makes sure that it's a second check to that individual so that they know where you are, what time they're expected to get there, that sort of thing. The other thing that I always put in a confirmation letter with the people that I am examining is sort of the expectations. I have some verbiage in there about individuals who can come to the evaluation or who can be in the room. That's a very important thing to understand. Again, there are certain jurisdictions, certain state laws, if you will, that oftentimes have something to say about that. I happen to live in a three-state area that has nothing about that in any of the state laws, so I get to set my own rules, and my own rules are is I don't want anybody else in the examination room except for the individual who's being examined. There are a few exceptions to that rule. Head trauma, one of them. If the person doesn't have good enough cognition to answer my questions, oftentimes I'll ask for a spouse or someone close to that individual to also come in. The other thing that I put in my confirmation letter is please don't bring your children. I don't know about your offices, but I don't run a daycare center in my waiting room, and that also has to do with regards to liability concerns. If these people are going to be examined by you, and again, remember what I said, hour at a minimum, three to four hours sometimes, what are you going to do with the kids if the kids come in? Don't let them in the examination room. That is terribly distracting, and in some cases, dangerous. You know how they are. They crawl over every place, and that's just not a really good thing, so leave the kids at home. Make some arrangements to do that because it's a focused type of an examination, and that's what we need to be concentrating on. Ask yourself also what laws govern the circumstance. Again, some state laws are very clear with regards to the rules around independent examinations as far as who can be in the room, how quickly do you have to have the report done, who can get the report, those types of things, so make sure that you understand what those things are. The other important part about clarification of purpose is to identify the reader and the level of expertise of the reader. I think that's critically important. You are writing to the individual who is asking you to explain things to them. What is the question that's going to be asked? Have you asked that question in language that can be understood? Who's going to be using the report, and for what purpose? Maybe it's within the context of an insurance company, and that's it. Maybe it's going to be used in the context of a very significant trial. Those are different types of things. Remember, however, that your independent medical examination report is a legal document, and it should be considered to be there forever unless you're told otherwise. I know for a fact, and I've been at this for 28 years, I know for a fact that there are attorneys in my particular locale that save independent medical examination reports, not only on me, but other people in my area that do them. Why do they do that? So that they can look back on them and try to catch you if you've changed your opinion on a particular subject or a particular topic, and they might use that in the context of the legal system. Complete preparation. Complete preparation also refers to reviewing all past pertinent records that are sent to you. Now, when you get into the complex independent medical examinations, these are going to be voluminous. Thank God for electronic records. It used to be that these real complicated cases, at least in my office, you'd always cringe when you saw the UPS or the FedEx driver come up. Sure enough, he'd take the two-wheel cart out of his thing, he'd have like four banker's boxes worth of records, and he'd come in the front door and says, hey, doc, where should I put these? Okay, well, thank goodness those days pretty much are over, because nowadays they will put those things on a flash drive, a CD, sometimes they will house them on a cloud-based type of record system. So it's very much better nowadays than what it was before. Oftentimes we get asked questions about, well, are non-medical records important in the independent medical examination? And the answer to that is it depends. There may be some non-medical record information that can be helpful to try to guide some of the decision-making that's done. Some of these things may be like work attendance reports. The other thing that's becoming very, very popular now is the requesting parties oftentimes will show you things from social media posts. And it becomes very, very common nowadays for folks to send me the TikTok video that they've made or the post on Facebook with the picture, these types of things. Why is that? Because it gets really at the idea of the claim, a person can't do something, oh, I can't go back to work, or I can't do X, Y, and Z, and then these social media posts show something completely opposite. So that's why that's becoming important. Surveillance can be very important, and there are a number of private investigation and surveillance firms that are out there in the United States that will follow people around and videotape them and document what they're doing on a day-to-day basis. Again, this is garnered at trying to either corroborate or argue against their claim that they can't do something. I will give you a little bit of a tip here with regards to surveillance. If you are given surveillance and you're asked to look at it, just make sure that you're darn sure that it's actually the person that's in the video that you're looking at. I had an example very early on in my career where I was given video surveillance on somebody who was changing a tire on their car after a flat, and it showed this individual getting the spare and the jack out of the trunk, jacking up the car, changing the tire, putting the tire back, and off the person went. This video was done at a distance of, oh, it was probably about 150 to 200 feet, and sure enough, it kind of looked like the person, you know, kind of same hair, kind of walked the same way and kind of acted the same way, so I didn't think anything of it. I do the independent medical examination, and I include, you know, my information about the surveillance, and we get into a deposition, and one of the first things that the opposing attorney asked me in a deposition, doctor, do you know that doctor such and such, you know, examined this person and came to an opposite conclusion? Well, no, I didn't know that. He said, did you realize that the person that you examined has a twin? Oops. Okay, so there we go. So even though the surveillance that's given you, you know, is advertised as being the person, be careful with those kinds of things, and it'll save you a lot of grief, so there we go. Oftentimes, they're going to send you x-rays and lab reports. I try to look at the x-ray studies myself. That sometimes is easy and sometimes is difficult, depending on where they're at and how they've been done and what the policy is of the imaging center or the hospital or whatever, as far as releasing that information. But I always try to look at those things myself. At the very least, look at the radiology report. I will tell you radiologists are human beings, too, and that they can make mistakes. That's the reason why I like to look at the study myself. But if that's not possible, at least get the radiology report so you have some degree of understanding as to what's going on there. One of the things I oftentimes tell people about preparing to do independent medical examinations is that understand that it's a different concept than what we're used to in the treating role. When we're educated through medical school and our residency programs, there's a lot of time that's spent on how to take a good history, how to do a good physical examination, for sure. And those things are important in the IME world as well. But it's different from the standpoint that then we're asked to formulate a diagnosis and in the typical doctor-patient relationship talk to our patients about treatments and follow-up and all these other types of things. And in the IUB world, those last things are not done. So it might seem a little bit odd to you. I always think it's a good idea to think about a script for history taking. There are many different examples that are out there as far as forms that could be used to make sure that you track and follow the things that you need to ask, and a script for the examination as well to make sure that you're not forgetting to examine a certain part in a certain way. So those things can be very, very helpful in the process. The other thing that I will tell you is that it's a good idea to think about preparation for what I call intangibles. Despite the fact that you'll have individuals that have gone through and signed the informed consent for the independent exam, and they've already attested to the fact that it's not a doctor-patient relationship, you'll still have people ask you treatment questions, and they'll still request you. And in the middle of the IME, frequently, I get the idea, oh, doctor, you're the first one who's ever asked questions about this. You're the only one that ever has seemed interested in whatever. Would you be my treating doctor? So you have to think about the answer to that and just be prepared for those types of things. The other thing that creates a lot of angst sometimes is requests for taping and recording. Now, again, you have to understand what your particular state law and situation says about this sort of thing. In my three-state area of Iowa, South Dakota, and Nebraska, I get to set my own rules on this, and I don't allow any taping or recording of the independent medical examination. There are some jurisdictions that do allow that, that allow the individual to have it taped. And the other thing that I'll tell you about that is that if that's the case, you may very well want to consider having it taped yourself so that there's a dual copy. Why is that? Tapes can be edited. If you're going to rely and trust on the individual that you're examining, that that tape and that recording is going to be accurate, not sure that that's a good thing. So think about, if you're in that situation, to also tape it yourself in your own way. Again, we talked about rules about who is in the room. Again, there are jurisdictional differences on this. Some state laws allow representatives to be in the room, even attorneys. So you have to know what the rules are in your particular jurisdiction. And then think about a script for conclusion. It's going to seem odd when you first start doing independent medical examinations that you stop the evaluation after you've done the history and the physical, because you're not going to interface with the individual you're examining about treatment options, differential diagnosis, medications, any of that kind of stuff. So it might seem a little bit odd to you. So think about how you're going to finish with that. Now, I think it's very important that we have all of our examinees sign notice of informed consents for the IME. In your syllabus that you have on the swap card, there should be a PDF in there of various different documents for various different things, one of which is the notice of informed consent that I use for independent medical examination. I'm not suggesting that mine's the best or anything like that. It's just an example. And you can tailor this as you see fit. There are many different examples that are out there. But basically, what this does is it sets the rules. It says that the person is going to be examined, that I'm going to take a history, that there's no doctor-patient relationship. It also says that I'm an independent party here. I'm not advocating for anything. I'm not going to be talking about you should go do this or you should go do this during the course of the examination. It also has an indication in there as to who's going to get the report. And again, in my jurisdiction, my area, the requesting party is the only person who gets that report. It doesn't go to the person I'm examining. It doesn't go to some other entity or whatever. It only goes to the requesting party. What happens if I get follow-up requests to get that report? I refer them to the requesting party because they're actually the one that owns the report. I don't own the report. The examinee doesn't own the report. The requesting party is the one that owns the report. So let's turn to content. We've done all of our preparation. We're kind of prepared for what's going on here. Some of this might seem like this is medical school 101. But I will tell you, in reading many IMB reports in my career, you'd be surprised at how this stuff is not paid attention to. So I think it's relevant to go through. As far as taking the medical history, the time and the circumstances of the onset are very critical. Is it a traumatic event? Is it a cumulative event? Is it some mix of those two things? Very important to try to figure all that out. Reviewing with the examinee the results and the findings on previous physical and mental examinations is extremely important. This is the time when you get to talk to the person that you're examining about what's in the medical record and if they think what's in the medical record is right, wrong, or somewhere in between. And if they think it's wrong, ask them why they think it's wrong. Part of the job of the independent examiner is to try to figure out or corroborate differences in what's being reported to you by the examinee and what is in the medical record. Sometimes that's a very difficult job. But that's something that we should try to do. We're going to look through results of prior tests. We're going to look at previous treatment plans with a focus of attention on what's worked, what hasn't worked. Very important thing is to figure out the compliance. This oftentimes is an issue when those folks come in as far as, well, they were supposed to have, what, two weeks of physical therapy and they only showed up once. Try to find out why that is. Many times the person will tell you, well, I went to the first PT visit and it made me hurt worse, so I just didn't go anymore. Did you make that judgment on your own? Did you get advice from somebody else? Those are things that can be helpful in trying to figure those things out. And then obviously, as we were taught in school, try to figure out those things that make the problem better. Try to figure out those things that make the problem worse. Get a lot of questions about history questionnaires and whether that's a good thing in the world of independent medical examinations or maybe not a good thing. I actually think it's a good thing, but there's some caveats about that that I'd like to bring to your attention. Number one, the reason that I think it's important is it does save us time. If you use an information or a health history form and you use a symptom diagram, which I'll show you here in a little bit about the one that I use, I think it can save you a lot of time during the course of the verbal history taking. I also think that it can be helpful as a baseline template because it will establish what that individual is telling you in writing at the time of the examination. And then that can be compared down the road if the symptoms change. It can be sent out prior to the independent examination. And I know a lot of my colleagues do that. What are some of the good things about that? If you do that, it's more likely to get complete information because the person can fill that out at their own time and go through it in a little bit more, I guess, easy way of doing it. And it does establish an examinee-created historical document. But the negative about that is that if you send that out ahead of time, you're never, ever completely sure if it's the examinee that's filling it out. And there are oftentimes cases where other people are filling it out, including their counselor or their attorney. So you have to be a little careful about that. Some things about the history questionnaire that can be also difficult is dealing with folks that don't complete it in its entirety. They will leave blanks on it. And some of the reasons why they leave blanks, maybe it's embarrassing information and they don't want to write it down. Or maybe they're intentionally omitting it because they're not willing to put in writing some important information that might otherwise jeopardize their claim or what have you. So just be aware of some of those trouble spots with regards to the history taking. Now, I do use a symptom drawing. My particular viewpoint on this is that I don't send things out to the individual ahead of time. And again, this is my personal view on this. What I do is I have people fill these things out in the office before I actually see them. So when I schedule an IAB in my office, I expect that person to be there 30 minutes ahead of time in order to complete the questionnaire, the symptom diagram. Most of the time, 30 minutes is plenty. I think the symptom diagram is really, really important because it does give you a very good idea of what it is exactly the person is complaining of. I don't use a diagram where I simply shade this part in or circle the part where there's pain or any of this kind of stuff. I actually use a symptom diagram. And I use a letter designation. A, for example, is aching. B is burning. C is catching. N is numbness. T is tingling. And here's what it looks like. So the person has the ability to tell me within the course of this diagram not only where are the various symptoms, but what those symptoms specifically are. And it helps me to try to focus in on where the problems are. So again, I think that's a very critical thing. Now, you might ask yourself the question, when does the examination in an IME actually start? And I will tell you that it starts when they pull into your parking lot. One little tip that I always tell independent examiners is it's very nice to have an office with a window that faces the parking lot. Because you can tell a lot by watching people walk into the office. And you can tell a lot about how people walk out of your office. And I can tell you a number of stories about how gate patterns change when they hit the front door. So just be aware that those things can happen. I also will tell you that there's been a number of times where individuals have come into the office and have had IMEs that have various different ambulatory assistive devices, canes, walkers, et cetera, et cetera. And there's been a number of times that they have forgotten them and left them in the examination room. That's all part of the physical exam. That's very important pieces of information that can be used. So that's a helpful little tip there. Now, before the examination, I do think it's important to go through with the examinee that we're not here to create any problems for you. So I advise the examinee not to do anything that's going to cause undue discomfort or perform any activity beyond their physical capability. And I ask them, you've got to tell me if I'm doing something here that's creating problems. And if there's any kind of a test that I'm doing, doesn't make any difference what it is, extremities, spine, whatever, that causes excess discomfort so that we can stop. I'm not here to try to make things worse for the person. Here's another thing. Oftentimes, we get a lot of questions about, OK, what do we do with wearing gowns and all this other kind of stuff? Really important to make sure that you inspect the skin with a lot of these types of problems and claims. So yeah, I mean, we've got to make sure that the person has suitable attire. We have a number of things in our office, different gowns, throw away shorts, throw away tank tops, all kinds of different options for people. Because they're not going to come prepared oftentimes or wearing the right things. Making sure that we drape things as necessary and providing a chaperone, I think, is very, very important. I'm to the point now where I chaperone everybody. I just don't even think about it, because I think it's very, very important. What about pre-printed forms? I think this could be very, very helpful, especially in complicated type of cases in the workers' compensation arena, where you have multiple areas of the body that have trauma. And you have to do range of motion evaluations for multiple joints. You have to do strength testing for multiple muscular problems and this sort of thing. I think that these worksheets and so forth can be very helpful to make sure that you don't forget something. And there's a number of those worksheets that are out there. Some of them are in the AMA guides themselves. Some of them are in other ancillary documents. And there are people that have these things on the web, too, that you can easily download. So whatever is comfortable for you. But I do think that those things can be very, very helpful. Please understand that during the course of the physical exam for an IME, that there may be components where you have to do certain things in certain ways. For example, if you're doing an IME and you're calculating impairment based upon range of motion, the AMA guide says is that you have to do at least three trials of that. They have to be within 10 degrees of each other. And it has to make sense. So it's not just, oh, well, we're going to measure it once, and then that's good enough. Because sometimes there's very prescriptive information, for example, in the guides themselves that tell you to do these things in certain ways. Non-organic physical findings can be very helpful. Looking at things like the Waddelsteins and those sorts of things can be very, very helpful to try to aid in the evaluation. Now, did you do everything that's necessary? For example, in an impairment rating focused on, for example, CRIPS, things about CRIPS. Did you document the skin color? Did you document the skin texture, the moisture? Did you actually measure the temperature? These things become very, very important. If you're evaluating somebody who's had a knee replacement, did you actually measure their knee alignment? Did you check for medial lateral stability? Did you measure that in degrees and record it appropriately? These are just examples of things that are in the AMA guides that are focused on the issue of how do you figure out impairment ratings for these things. So if you don't understand what the rules are, you're not going to be able to get anywhere. And you're going to look kind of silly if they ask you about these things and you haven't done them. One thing that I think has been very helpful since the advent of digital cameras is digital photography. I take a lot of pictures during the course of my IMEs. I think it can be very helpful for burns, scars, and those sorts of things. Also, amputations, CRIPS, I think is a really good and helpful thing here because a lot of times the folks that claim that they have CRIPS, I'm taking a photograph of one extremity. I'm taking a photograph of the other extremity that doesn't have any problems. And in a lot of cases, they look exactly the same. And it's like, OK, I think that helps from the standpoint of trying to bring some clarity to that. There are some instruments out there that do computerized testing of motion or strength. I don't particularly use those myself, but I do know that some of my colleagues do. And if that is the case, make sure that you include that information within the physical examination part. Now, some things about the physical exam. When I get towards the end of my evaluation, there are three questions that I will routinely ask to make sure that I have been complete about what I'm doing. One of those questions is I ask the examinee, is there anything else you think I should check? I like to think that I'm thorough about what I'm doing. But in some cases, maybe not. Maybe the examinee has got a concern about some other part. Maybe we're looking at a low back thing, and we're kind of focused on that. But they say, well, could you examine my neck and make sure that that's not a problem? Sure. What that does is it ensures that you're being comprehensive, obviously. But I think it helps your credibility, because you're actually getting that feedback from the individual, and you're being responsive to what that feedback is. Another question that I ask is, how are you doing? Most time, people do fine. Sometimes people aren't doing fine. And if they're not doing fine, I think it's a good practice to document as to why that is. Then the last question, which is very, very important. Once I've completed the history, and I've done the physical exam, I ask the individual, is there anything else you want to tell me? You'd be surprised what that question sometimes can do. I've had examples where that has opened up dialogues about some mental health things that wasn't in the records before. It opens up particular social and individual challenges that the person is having, family members, spouses, kids, financial concerns, all kinds of things that come up. So I always think that that's very, very helpful in the process. So what about the examination? Be thorough and document that you were thorough. Measure and record everything germane. Chaperone everybody. Take time to write things down. This isn't like a sprint. This is more like a marathon. You will have examinees that talk quickly. And this might be difficult. Don't be afraid to call a time out and say, OK, you've given me lots of information here. I want to make sure that I have this written down the way that you've just described it. There's absolutely nothing wrong with taking a time out like that. Try to be consistent in your approach and your tone and your demeanor. What I mean by this is that you basically kind of want to have the same approach for every IME that you do. It's not supposed to be like highs and lows and all that kind of stuff, but be pretty consistent with things. Document beginning and conclusion times. Critically important. The number one complaint that an examinee has during the course of the independent exam is, the doctor didn't spend enough time with me. So if you document when you started and you document when you finished, it goes a long way to try to mitigate those types of complaints. End with a thank you. I try to make the process as pleasant as I can for the individual. That is not necessarily easy. A lot of folks that you'll be examining in the context of an IME do not want to be in your office. They have what I call mad at the world syndrome. And anything that I can do, even to be nice, have my staff be nice, sometimes isn't going to make a difference. And sometimes you kind of got to just wade through those things. But I try to be overly nice with people. I train my staff to be overly nice. I offer assistance at the exam. Hey, do we need to call a cab? Can we get you a glass of water? Can we go get you a soda? I think that stuff goes a long way. And eliminate interruptions. We're all busy folks. OK? I have a rule in my office that I don't want to be interrupted in an IME unless the building is burning down. And I mean that. Because if you have a bunch of interruptions, it doesn't project professionalism. It makes the examinee think like, well, you got other things that are more important than paying attention to why I'm here. So I try to eliminate those interruptions as much as possible. Speaking of interruptions, can I ask you a question about that? What do you do? I'll repeat your question. That's fine. What do you do when you find somebody that no one else has identified? I mean, what we've been doing is just putting commentary in the questions or the answers and say that. And if we have to, we'll send a friend as possible. But it comes up fairly often. So the question is, what happens in the context of an independent examination where you have a medical finding that nobody else has found yet? It depends. I mean, if it's an incidental thing, that it really is not an urgent type of thing, then I think it's OK just to document that in the report and make a suggestion in a report that they go back to their primary care doctor or whatever. I think the more critical thing is though, what do you do when you find something that's either urgent or semi-urgent, and what do you do? Yeah, you give a great example like, oh, this person's got a heart murmur. Oh, they have an arrhythmia. Oh, they're an atrial fib. This is not a good thing. What do you do? OK, so just because there's not a doctor-patient relationship technically, that doesn't mean that it avails you of doing what a common doctor would do. I have sent people to the emergency room when I've seen that. I have also picked up the telephone once I know who their primary care doctor is, and I call the primary care doctor. And I say, hey, I got such and such here in the office. I'm doing an independent exam. I see this. What do you want me to do? Now, 99% of the time, they say either send them to my office or go to the ER. But I've done my due diligence in making sure that the person has gotten a directive to go do something based upon what I have found. Yeah, I think this is the one place where IME doctors can get sued. Yes. There are some legal cases that are involved with this type of a scenario, where there are new things found in an IME, and the communication didn't quite go like it was supposed to. Examples, looking at a chest X-ray, everybody else that looked at the chest X-ray called it normal. It's not normal. There's a spot on it. Uh-oh, it's lung cancer. What's the obligation of the IME doctor in that type of situation? Well, you've got to tell somebody. Just don't put it in your report and think that magically somebody is going to take care of it. So it's what we would be expected to do. And you're not going to get yourself in trouble for that. I mean, it isn't like, I think a lot of times people are so focused on this no doctor-patient relationship that they think that that somehow trumps everything else. It doesn't. You've got to do what makes sense. All right. Satisfaction or exit interviews, very important. I give one to everybody at the end. What does that do? Actually, it's kind of a feedback thing for me. Continuous improvement with regards to the process. I have a question in there about were the directions to the office clear? Did you have any problems with it? I have questions in there about what was your experience with the IME process itself? I have a question in there. Did anything that I do during the exam cause or worsen any symptoms? Then I ask them to give that rating on the five-star scale that we all know about. And then a place for any other comments. And here's an example of what I use. Again, this is in your syllabus, and you're free to copy it or mend it, edit it any way that you want. This is proven to be very, very helpful, especially in those situations where I've done the exam, I've issued my report, four months down the line, I'm scheduled for a deposition, and there's a claim that's been made. Oh, doctor, you injured the person in the course of your IME. That's news to me. According to this IME exit survey, according to this IME exit survey, this person said that they were fine at the end of the exam and had no problems and that I didn't make anything worse. Good response to those kinds of complaints. So next scene, communication. What about the medical report? I kind of alluded to this before, but understand it is a script for later testimony. Oftentimes in the IME world, you're going to have other things that are going to come up. Deposition, trial testimony, all those types of things. Again, know that these medical reports are permanent. I have done a thing that I would suggest to you is not a bad idea. I keep a reference file. I get to review a lot of independent medical examination reports of other people, and I sort of have a file where I keep good examples and I have a file where I keep bad examples and I go back and forth and I look at those things frequently because it kind of helps reinforce things in my head about my quality. Quality assurance with colleagues. If you have somebody that you know that does IMEs, maybe not locally, but in other parts of the country that you can share reports back and forth and kind of critique each other, that's not a bad way of trying to improve your processes. Oftentimes we get asked, what should be in the report? Well, there's no hard and fast real answer to that because it depends upon the type of the IME and it depends upon the jurisdiction that it's being done. But I kind of throw these seven bullet points in here just because I think these are kind of foundationally the things. Now, you may not necessarily think about all IMEs in the context of these things, but I do think these things are kind of foundational. There should be an introduction section. The person needs to be identified. You should identify where the referral source is. Such and such has been scheduled for an IME at the request of such and such attorney or such and such claims representative or what have you. Also talk about the purpose of the evaluation. This IME has been scheduled to answer questions of return to work, impairment rating determination, whatever. Somewhere in your report, you should have a listing of all the things that you have reviewed. Records, reports, radiographs, and so forth. My preference to this is to put that in an appendix list at the back of the report and not put that within the context of my report because I think it makes reading of the report easier. Again, I'm always focused on who's reading it and how easy or difficult is it going to be for those folks to be able to wade through that stuff. As far as the history portion of this, I like to tell a story. Now, there's a lot of discussion about stylistic approaches as far as how the history is included in a report. Some examiners like to go through the history and have very rigid sections about, OK, I'm going to tell you what's in the records that I've looked at. And now I'm going to tell you what the examinee has told me. My preference is to not do that. I like to intermittent and mix those things together. So I'm telling a story. And I'm going through that story from the beginning of the complaint to today. And I'm talking about the previous things that have been done. And then I'm interjecting what the examinee is telling me about that. So my style is a little bit different. It's more of a storytelling approach. I'm not here to tell you one's better or one's worse or whatever. You've got to figure that out yourself. But there are different stylistic approaches to these types of things. But just make sure you're complete. That's my message for you. It is important to differentiate whether the information you're talking about is from the record or from the person. And obviously, if those things conflict, hopefully try to figure out why that is. When we talk about findings from previous exams, things to focus on, pertinent, positive, and negative findings, obviously, if there has been previous documentation of validation signs. These are things like Waddell's tests. There's a goniometer check for validity of range of motion of the lumbar spine, for example, that previous editions, they make guys talk about. If you have that stuff that's in those records, great. It can be very, very helpful. What's the ability to dress, undress, get off and on in the chair, move around, those types of things? How do they walk in and out of the room or the parking lot? We talked about that before. Report required observations under disability system of record. I talked a little bit about that before. In documenting certain things in your clinical evaluation, you may need to report those things in certain ways. If it's an impairment evaluation based upon a particular edition of the AMA guides, you may need to record flexion of the knee in a certain way. I'm just bringing that up as an example. So know what those things are. Again, we talked about discussing findings from lab tests and diagnostic procedures, and then any results of a specialty evaluation that may have happened. Another section of the report that's important is clinical impressions. Most people usually say this is the diagnoses, and that's fine. Most of the time, these things are listed numerically or in a bullet-pointed format. Please make sure that you list those things to the point. Some people like to use the ICD-10 designations. That's fine. But this is not the part of the report that should be a narrative. I see a lot of reports where in the diagnosis section or the impression section, it says, low back pain exacerbated by a motor vehicle accident of January 2020, above and beyond previous degenerative disc disease at four levels, blah, blah, blah, blah. No, that's not the diagnosis. That's a descriptive term. The time to talk about the exacerbation and the other stuff and how all that related is in a different part of the report. Oftentimes, an important part of the report is an assessment of the current health status. Here's some questions to think about. Is the clinical information sufficient to assess the individual's current health status? Sometimes in the context of an IME, you'll go through it, and the answer to that will be no. Maybe there's some other testing that needs to happen. Maybe there's a critical part of the treatment that has not yet happened. So we can't judge as to how things are going to turn out. Another question, very important in the workers' compensation world, is that individual at maximum medical improvement or MMI? That basically means all the medical care is going to be done, has it been done, no additional medical care is going to make a difference with regards to the situation. And you should be able to support that conclusion, obviously. Now, that doesn't mean that a person could be at MMI and that they might get worse. There are known medical conditions that, despite medical treatments, were not going to get better. But there's a certain degree of deterioration that we know is going to happen. Arthritis is a good example. Lots of things in the internal medicine world, pulmonary conditions, cardiac conditions, are like this. And if that's the case, explain that in your report. Why do you do that? You might be able, for example, to give somebody an impairment rating on the day that you see them. But depending on the system that they're in, three years down the road, five years down the road, seven years down the road, if the situation worsens, they may be able to open their claim again and ask for a re-rating. So if you clue the individual in your report that that's a condition where that might be the case, that can be very helpful. Oftentimes, we're asked about, what is the health status and its focus on impact on performance? In the context of return to work, can the person go back without risk of harm to themselves or others? What is that in regards to the impact of their employability and then also on other life activities? Many times, the questions that are asked of the IAB examiner is, tell us what we need to do next with this person. That's the medical management plan. Again, sometimes IAB is not going to be focused on this, but it is. In this scenario, you're going to want to know recommendations for further diagnostic testing. Address that. Maybe the person needs to be referred for a specialty evaluation of some sort that's not yet been done. In some cases, the condition will necessitate periodic re-evaluations. For example, head trauma that leads to a seizure disorder. Somebody may want to know, well, what's reasonable as far as visits with a neurologist, medication checks, and all this kind of stuff. Sometimes people ask questions about rehab. OK, this person has had this surgery, or they've had this done. How long should their rehab be? They're asking a question to try to gauge what that should be. And then should there be any follow-up to your evaluation? Maybe the person is not at MMI. They were sent for an impairment rating. You've got to be the guy that says, hey, this person is not at MMI. These things need to happen. They want to know, when can I schedule this person after all that stuff is done so that we can get the rating done? That's where that's coming from. OK? Another part of the report, what I call discussion. What do we mean by this? You're going to review and analyze the documentation. You're going to explain in your report, does this fit with what the person is telling me, or doesn't it? Are there any holes that need to be filled in? If you're asked a question about causation, go through that process. That's a whole other lecture, as far as how to do causation evaluations. OK? Comment on appropriateness of prior treatment, the likelihood the medical condition is going to improve. And then, of course, the restrictions, specifically in the work hop world, becomes very important. Does a person need temporary restrictions? Do they need permanent restrictions? And then, especially in the cases of the long-term disability evaluations, does the examinee meet the disability criteria under which the exam is conducted? If it's an impairment determination, make sure that you know what edition of the AMA guides your particular state uses. There are some states that don't use the AMA guides. So if you have a state-specific guides, make sure that you're using the right information. Are you fluent in the AMA guides? Some are, some not so much. What about peer review of impairment reports? Again, just like I said before, sharing information with colleagues about the quality of your report and also sharing information about accuracy of impairment ratings can be very helpful. In some cases, in order to provide impairment ratings, you might need to have specialized equipment. For example, in vision impairment ratings, you have to have visual field testers. Maybe you don't have that. And if you don't have that, get to be best buddies with an optometrist or an ophthalmologist who does, who can provide that information to you. Oftentimes, you're asked about, what's the burden of proof on meeting a certain disability, employability, or accommodation? If that burden of proof is not met in your mind as you go through and you analyze the question that's been asked to you, explain in your report what needs to happen for you to be able to make that determination. Understand that in our reports, our conclusions are always expressed within a reasonable degree of medical certainty or probability. Those are certain important legal words that need to be in the report. Very important from a jurisdictional standpoint. Disclaimers. I have a number of disclaimers to put at the end of IME reports that are in your syllabus. I have to recognize Gary Freeman, who is one of my mentors in the ADEP organization that basically is responsible for writing a lot of these disclaimers. And essentially, the disclaimers get at the idea that I'm making my determination based upon the information that I have, and that if new information becomes available later down the road, that I reserve the right to change my opinion. That's very important, because in many cases when you're doing an IME, you don't get the entire medical record, and sometimes the information that's missing is really important. So it gives you the ability to then look at that information in the future and not get yourself into all kinds of problems. Good idea to tell people how to get in contact with you if they got more questions. Some other items that are related to this whole report writing and IME process that oftentimes I get asked questions about, coding and billing, really shouldn't be an issue in the world of IMEs, because it's basically supply and demand, billing type, what's reasonable in your community. But the reason I bring this up is if you live in a world like I do, where you're an employed physician and you're paid based upon an RVU system, there are no RVUs for an independent medical evaluation. So what does that mean? No, I don't work for free. But if you're in that type of an environment, you're going to have to figure out what an RVU should be for an IME, and you're going to have to negotiate for that and agree to that. Not going to spend a ton of time on that, but it is important. What do I mean by nomenclature consistency? When you're writing your report, try to be consistent with regards to your writing styles and how you identify things. There's a lot of variability on that. People start to wonder about your credibility and those types of things. It's fine to use references in your IME reports, specifically if it drives a point home that you're trying to make. Can also be very helpful in the causation analysis. If there's certain articles that you are relying on to make your arguments, that can be very, very helpful. Use addenda. Again, I think that's a very important thing. The context of my reports, again, I'm telling a story. It's easy readability. If there's complex information that's better in an addendum, I leave that to the end. Obviously, if you're doing this for purposes of impairment rating, hopefully you've had some AMA guides training that you can rely upon for that. What do you need to understand about the report? Understand that it's going to be read by many. It does project your credibility. We talked about that before. It markets your performance. I'd like to go over just some stylistic points with you. Obviously, I can't teach you English and grammar, but this is a big deal. I will tell you that, by and large, doctors write poorly. I can't tell you how many times I've looked at IME reports where there are incomplete sentences, paragraph structures that make no sense. Maybe some reports that don't have paragraphs at all is just one big run-on paragraph. These things are not good. One suggestion that I have for you is it should move the reader forward. If you read it, you should be anticipating information on the next page. One of the things that's helpful in that is read it aloud yourself. If it sounds goofy, it probably is goofy. It's always important, I think, to write to persuade. Not like so aggressively that it jumps off off the page, but it should provide a persuasive argument that leads to the conclusions that you're trying to make. Certainly fine to use analogies, but don't do that all the time. That can be kind of wonky when you read some of the reports that have analogies all over the place. I like to use subheadings, and I break my reports into different subsections. The reason I do that is because oftentimes, my IME reports are read by different people for different reasons. For example, if it's in a work comp environment, you might have one person that's paying attention to the impairment rating, and that's really the only thing they care about. You might have a different person that's worried about the return to work, you know, do I suggest restrictions or work activities or whatever. You might have another person that's oriented on just trying to figure out how much additional things have to happen with maintenance, care, or whatever. So putting those things in subheadings can be very helpful. Obviously paying attention to sentence length and paragraph length and verb tense and all those types of things are very important. Things to avoid, and I have to catch myself particularly on that last one a lot, because I have a tendency when I get going to throw these what are called wasteful or no-no words in there. Things like totally, absolutely, completely, basically, essentially, clearly. You can take all that stuff out of your report because they don't add to anything, okay? Be careful about template reports. I know some IME providers who, you know, you can pretty much know what your report, their report's gonna say before you even pick it up. So try to avoid that sort of thing. Pay heed to the reader. Some readers will read your report as the 10th of the day, so you need to stimulate their interest. Again, you're writing the report for the reader's convenience and not the writer. If you have complicated or complex medical terminology, it's not a bad idea to insert a glossary and define those medical terms and always be consistent with numbers and data, okay? Other helpful hints. Don't use the word patient in the context of your report. Why? That will establish a doctor-patient relationship in some jurisdictions just by that, and that's a problem because this is not a context where that should be the case. Please don't include in your reports any inference to treatment. There's another thing that can be interpreted as establishing a doctor-patient relationship. Pay attention to time deadlines. Sometimes these things are hard to get done in the timeframe that they're expected. You might have a scenario where you're working and doing these IMEs for one of the third-party vendor companies that has specific rules. Your report has to be within five days. Are you able to do that? You might get a call from an attorney. Well, I really hate to ask this, but we're going in front of the hearing officer in three days. Can you see this person and get a report done before then? You've got to make that decision up on your own. Maybe you've got the bandwidth to do that. Maybe you don't. You have to figure out that stuff for yourself. Please answer all questions that are posed to you. I require a cover letter to be sent from every requesting party that has questions that they want to have answered. In my reports, I have a specific subheading that's titled Specific Questions to be Answered. And I bullet point those and I repeat what's on the cover letter. Question number one, quote, is this individual at maximum medical improvement? Question mark, unquote. Answer, yes, no, why? Those types of things. If you do that, you'll make sure that you don't miss anything. Thankfully, in the days, in times here where we're doing a lot of these things digitally and electronically, we don't have to worry about lost dictation in reports. But, having said that, if you do save these things electronically, make sure you have a backup. I think most people know that nowadays. How do you make sure that you're doing a good job? In your syllabus, there is a copy of what's called the ADEP Peer Review Template. Not used by ADEP anymore, or IAIME, but it was developed as a way of doing peer reviews for individuals who were submitting for fellowship in ADEP. And just so you know, the person had to submit four examples of reports. All the specific information was rejected. But there would be a committee of folks that would go through and look at those reports and give feedback, and kind of a grading system, if you will. And that peer review template were sort of the focus areas of content where these things were looked at. So that can be helpful. Other methods of peer review can be very helpful. Here's what this fellowship gradation scheme looks like. And I know you probably can't see it on the screen, but again, it's in your syllabus. That can be very helpful. Some other things to talk about. If you are an old dinosaur like I am and still dictate into a telephone and have somebody from afar transcribe your reports, dictate same day if possible. Establish a pattern. Try to be consistent. Meet with your transcriptionist regularly so they understand what in the world this IAIME stuff is all about. Because usual medical transcriptionists don't have a clue. And it's a report structure and format that they will not be familiar with. Slow down. Everybody, I think, is guilty of talking fast, I think, at times when that can be a little bit of a problem. And obviously, establish a protocol for proofreading, corrections, and so forth. Please note that in your report that your error rate directly correlates to your credibility. If you have complicated data, tables can oftentimes be very, very helpful. I include the pain diagram and the symptom diagram in my report because that projects thoroughness and that you actually have done what you say you're doing. It's okay to use boldface, italics, and underline, but don't get carried away with that stuff. It's basically to make sure you're emphasizing a particular point. And again, a lot of reference materials in your syllabus about report mechanics and guidance with respect to that. For the last part of the time that I have with you this morning, I want to talk a little bit about not in-person independent medical examinations, but what I call independent medical evaluations, which are things like file reviews and so forth, and just let you know about what those things are about. Now, one of those is what's called the pre-certification or pre-authorization report. Usually these things are a very close network of physicians that do this sort of thing because it does require experience and current knowledge in a lot of the literature and current standards. It does require a knowledge of certain practice guidelines, especially in states where this is jurisdictionally mandated. So for example, Texas, for example, in their work comp system, uses ODG and the MDA guidelines for treatment and disability duration and those types of things. So you have to be well-versed if you're asked to do those things in that jurisdiction. It does oftentimes require a peer discussion. You have to pick up the telephone to the treating individual to try to have a dialogue with them about their justification or rationale for doing things. So that's one thing. The pre-certification report is a report to determine whether or not a clinical procedure or a diagnostic test is reasonable or medically necessary. Frequently comes up in the surgical world when, for example, you might have a spine surgeon that wants to do a three-level fusion and you're asked, okay, does this make medical sense? You go through the process, look at the records, pick up the telephone, try to have a discussion with the surgeon about that, and that's what that's all about. The peer review report is essentially an IME without the examining encounter. So you're gonna go through the records and kind of go through the same mental formulations and processes as you do with an in-person IME. It does require an analysis of the treatment protocols and diagnostics that are based upon current accepted guidelines. This is not a shameless plug, but obviously our ACOM practice guidelines are oftentimes used for this. There's another competitor called the Official Disability Guidelines, Treatment and Workers' Compensation, that are also sometimes used. And then there may be certain other individual specialty-specific guidelines that come into play. So for example, the American College of Radiology has guidelines on imaging. For chiropractic care, there are chiropractic quality assurance guidelines, commonly referred to as the MERCI rules, that can be helpful with that sort of thing. So the approach here is basically the same. As far as the analysis is concerned, you're looking at the previous record, you're trying to gauge that against the guidelines and against that other information to try to come up to a conclusion and answer questions that are posed to you in that file review or peer review process. Now some common questions that can be asked, and we get asked questions about this all the time, so what are some of these common things that we're gonna be asked about? We can be asked about the extent of injury. Again, we talked about causal relationships. Is the treatment reasonable and necessary? What future treatment will be necessary? Are certain medications okay, maybe not okay? Those types of things. What are long-term side effects from medications that are being prescribed? Are there over-the-counter medications that could be utilized instead of prescription medications? What are typical utilization timeframes for certain medications for the condition that we're looking at? Based upon the documentation and mechanism of injury, what is the compensable medical diagnosis? Does anybody know what that means? You need to know what that means within your jurisdiction. Causation is not necessarily the same as compensability. Causation, we can comment based upon a scientific analysis, compensability is a social construct, meaning what does your state law say under workers' compensation that qualifies? And there are different rules, depending on different states with respect to that. What's the patient's prognosis? Are their office visits to the treating doctor in the future reasonable and necessary? Do we need to have further diagnostics done here? Is the claimant a surgical candidate? Is the proposed surgery reasonable to the compensable injury? Is there a need for a second opinion? Is there a need for a referral to a different type of physicians? So those are the types of things that we look for in an independent file review. And I did leave a little time here at the end for any questions, if anybody has any. And while I'm looking at the audience, I also will be looking on the chat to see if there's any online as well. Yes, sir. You said don't use the word patient. What should we use, please? Okay, so the question is, is don't use the word patient. What do I suggest? Examinee is what I use. Evaluee, you can simply identify them by name. Mr. X, Ms. Y, those types of things. Any of those things are fine. Just don't use the word patient. Other microphone, yes, sir. Excellent presentation. Just a quick question. You commented on the IMEs and the peer reports, but the algorithm of the process with the IME and these peer reports, there's usually some kind of follow-up or engagement, from my understanding, with either attorneys, insurers, or whoever you're referring to. Can you comment on that process and also, does that lead to a court engagement? And if so, what percentage, based on industry or GEMS? And you're right. A lot of these things that are instigated by attorneys and claims managers with insurance companies do wind up in a medical-legal context, for sure. As far as statistically how often that happens, one thing that I'll share with you that practically every attorney has shared with me who has ever sent me an IME, litigation's expensive, so they generally try to avoid litigating it if they can. Now, there's some caveats to that rule, depending upon which system that you're involved with. High-stakes systems, railroad, FILA cases, Jones Act cases for maritime. You're talking about claims of seven or eight figures. Oftentimes, more of a chance for litigation there than, for example, your state workers' compensation systems, where maybe the claim payout is in the tens of thousands. So, I don't know if that helps. I mean, it all kind of depends on where your referral sources come from. I don't know if this, I mean, I do all kinds of different IMEs for all those things that I just listed. And how often do I do a deposition? Maybe 10 a year. How often do I go to court and to actually testify? Once or twice a year. And you do get compensated for your time, or is that part of the IME report? Of course, I don't work for free, nor should anybody else. So, we haven't talked about expert witness, testimony, and all those kinds of, that's a whole different course. But yeah, I mean, you gotta figure out a fee structure for that. What kind of rules are you gonna have for that? If you gotta travel to go testify someplace, how does all that fit within a compensation structure? And you're obliged to follow up with that once you engage with the IME. You bet. Thank you very much. You're welcome. Yes, sir. I have two fairly straightforward questions, and they're both, I'm looking for some clinical pearls. The first question is, with the knee and measuring medial and lateral laxity, or varus valgus laxity, given that you have to use two hands to really assess laxity, how do you like to assess the angle that you're achieving, or how do you measure that angle when your hands are on that knee? So, this is a good question, and illustrates another reason why I chaperone everybody, because my chaperone is typically a medical assistant who I ask and instruct to do those measurements while I'm actually doing the physical maneuver. This is a little bit of a pearl. The chaperone can be doing lots of other things other than sitting in the exam room in the corner falling asleep. Get them actively engaged in the process. I don't do this. I know some examiners that actually ask their chaperone to be like a secondary note taker. Nothing wrong with that, but you can get them actively involved in the examination process, and you're right. In some cases, it does require more than two extremities to do a physical examination technique and measure something. You are correct. My second question is, on measuring sacral angle, do you do that on the person, or do you actually measure it radiographically, and which method do you think is more accurate? So are you referring to sacral angles for purposes of range of motion measurements or sacral angles with respect to instability of the spine? The former, particularly as it relates to the fifth edition guide. Okay, that's helpful. You're asking this from a fifth edition perspective. Yes. So I measure it on the individual, no x-rays. No x-rays. Because that's the way the fifth edition tells you to do it. But it's easier and more accurate to do it from an x-ray if you have one. I'm not gonna argue with you on that. Okay. But that's what the fifth edition says to do. Great. And again, you gotta understand the rules to play the game. Agreed. All right, thank you. You bet. Hi, Paula. Hi. Couple of caveats that I've been aware of recently is gender. And being consistent on gender in your report and being very careful to inquire, are the he, her, him, they, their person. And being an old person, it's really easy to mess up and use a gender that is not the preferred pronoun. Right. So I've had to really edit my reports when I'm reading, when I'm dictating those. Yes. The other is on investigations. One experience years ago, I had an investigator bring in a videotape of ostensibly my patient. The videotape, they're showing this person leaving the front door of the house and getting in their car and driving to a workplace where their car then sat for eight hours. And they didn't follow them on the return trip home. The person they videotaped looked nothing like my patient. We're talking short, bald guy versus tall, furry mountain man. And I'm looking at the investigator and saying, why are you showing this to me? This isn't my patient. So I discussed it with the patient on the next visit. I said, did you move? You know, they showed me this video with this address. And there's this person who came out of the house and who looked like this. And you know, you got roommates living in the house or something. His face went stark white. And the answer was he, because he was home all day alone, because he was off work because of the injury, he would go over in the early morning and have coffee and breakfast with his parents who lived a half a mile away. The man coming out of the house was the man that he discovered that his wife was having an affair with. So be careful when you're watching the videotapes. Perhaps that surveillance was now going to be used in a slightly different legal affair. Yes. Yeah. Yes, sir. Hi, a question from Fifth Edition. Knee interval, cartilage interval measuring. Typically, or oftentimes, obviously, radiographic reports don't have that. Then you get maybe an MRI report that may say moderate osteoarthritis. The X-ray report says mild, maybe, or even severe. And then you get an arthroscopic report that says something else. So how do you deal with that? What's your process? So what's the Fifth Edition say in the arthritis segment of the lower extremity? Standing X-ray. Thank you, that's the answer. Except how do you get the pre or the change? I completely understand what you're saying. You gotta understand that the Fifth Edition is how old now? 20 plus years old, okay? But that's what the rules say. If you have a state that uses the Fifth Edition, you gotta use what the rules tell you. Sorry. Okay, let me just check the online chat here to make sure that something hasn't popped up. How and when do you inform the patient of your conclusions? How do you handle that conversation with the patient while they are in the office during the exam? I don't, because in the context of the independent medical examination, I'm not discussing with the examinee my conclusions. I'm not telling them the diagnosis. I'm not telling them a treatment. In most cases, I can't calculate the impairment rating in the exam room. I have to go back and look in the guidance book and do a bunch of calculations and that sort of thing. And so, you know, I don't. If the examinee asks me about those types of things, I simply tell them I'm sorry, but that would connote a doctor-patient relationship. And again, I refer them back to the Notice of Foreign Consent. Hopefully they remember that they read it and sign it. But sometimes I will bring it up again to kind of go through those things with them. All right, so that looks like that was the last question in the chat. So I want to thank everybody for being here today and thanks for your attention. I hope you have a good rest of the conference. Have a good rest of the day. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

independent medical examinations

file reviews

high-quality medical reports

four C's of IME

evaluation standards

thorough preparation

non-organic physical findings

digital photography

physical examination

consistency

start and end times

occupational medicine