Maximizing the effectiveness of an IME report.

Maximizing the effectiveness of an IME report.

Sue DrewState Manager SA/NT

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This Presentation

• The IME– What is it ?– Why request one?– What will it include?– What to ask and why?– What makes a good IME report?

• Why medical opinions differ• Translating Medical Terms & Phrases • Decoding Specialists

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What is it ?

The IME

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• Why request one?• Clarification of diagnosis and review of other medical reports

• To access an extensive history not available from the treating practioner

• To move the claim forward if protracted

• Clarify present and future treatment if protracted

• Access sufficient definitive medical information to accept or reject a claim with confidence

• Assist in the management of non compensable illness and injuries impacting the workplace

• No current medical authority on file

• Assessment of Residual Disability/Permanent Impairment

The IME

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The IME

• What will it include ?

• A comprehensive history of Occupational duties & employment, mechanism of alleged injury/ sequence of events • Current status• Present treatment• Past medical history• Personal /Social history ( limited due to privacy)• Physical examination and investigations• Summary and Assessment• Answer to referrers questions

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The IME

• Alternatives to an IME?

• Case Conferencing with the medical specialist.

• File Review

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The IME

• What makes a good IME

• The quality of an Independent Medical Report is highly dependent on the questions you ask and the collateral information you supply.

• So what do we need from you?

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Collateral Information

• Employer reports/records• Factual Investigations• Accident/incident investigation reports• Other Medical reports• Investigations – X-rays, MRI’s, CT Scans etc• Surveillance reports +/- video evidence• Treating doctor records• Pharmacy records

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Language is important

• The questions you ask must have the same meaning to you as the Medical Examiner.

• For example the word ‘significant’ (which can have statutory meanings) may need to be specifically defined. In some jurisdictions ‘significant’ means the most significant of multiple causes, in others it means more than 50% contribution.

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“Significant”

• This word has numerous legal definitions and an even greater variety of general community interpretations.

• Regarding causation (where there are multiple component causes) does “significant” mean a particular component cause is

– More than 50% of the sum of all the component causes?

– The single greatest component cause? • Consider an alternative approach:

– Ask the examiner to apportion the relative importance of the component causes

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Causation

• Often impossible for the consultant to accurately apportion these matters where:

• Problems have developed over a long period of time.• There are multiple factors involved.• Underlying disease or degeneration is present.• A lack of medical investigations and reports over that

period of time.• Worker is a poor historian.• Examiners can provide estimates of the relative (as

opposed to absolute) contribution of various factors.

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Effective Question Design

• Avoid leading questions (they can suggest bias on the part of the referrer).

• Ask the examiner to comment, where appropriate, on inconsistency.

• Ask whether the differential diagnosis includes factitious disorder or malingering.

• Use clear and decisive language. Be aware that the words may have multiple meanings and interpretations.

• Don’t assume all consultant specialists understand SA Workers Compensation legislative requirements.

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Effective Question Design

• Cover one subject or point per question (double barrel questions can be confusing and the second part can get missed by the consultant!).

• Avoid questions requiring Yes/No answers, without also requesting reasons for the opinion.

• Avoid repetition(asking the same question in slightly different ways).

• Present the questions in a logical sequence.

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What makes a good IME report?

• The questions answered in full.• Identification of medical and non medical issues.• Consideration and recording of available clinical

history.• Relationship to an alleged mechanism of injury be

clear and evidence based.• The diagnosis must be complete, consistent and

definitive giving a balanced opinion using evidence based medicine.

• Clear, decisive recommendations addressing future treatment needs.

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What makes a good IME report?

• Any inconsistency be addressed and explained.• Opinions must be only expressed within the specialty

area of the consultant.• Prognosis and/or timeframes stated clearly and must

be compatible with the diagnosis.• Functional capacity and/or work capacity be clearly

defined and compatible with the diagnosis.• Availability of the specialist for discussion, report

clarification or supplementary reports.

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“Sample” Questions for Reports

• Please refer to the handout for a list of suggested questions for Psychiatric assessment.

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Reasons Why Reports Differ

• The way questions are phrased will influence the way they’re answered.

• Differing agendas by the referrer will result in significant differences of approach to the same problem, providing different information, resulting in varying interpretations.

• Some questions requested are simply unable to be answered definitively, ie % of degenerative change from 3 different injuries or accidents.

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Reasons why reports differ

• Workers present differently on different days to different Doctors.

• A lack of collateral information results in reports being

based entirely on information provided by the worker.

• Not using a coordinated approach with multidisciplinary reports.

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Avoiding the pitfalls of multiple opinions.

• Ensure multiple report requests (for the same worker) keeps each specialist in the loop of knowledge.

• E.g.Orthopaedic Surgeon and Psychiatrist or functional capacity and Occupational Physician.

• Ensured appointments are timed in such a way as to provide the primary with the others opinion and ask them to comment on it.

• Tailor your standard questions to each doctor.• The objective is to move your case forward not end

up with expensive medical opinions that are of no benefit to the employer or worker in moving forward.

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• How many times have you looked at the indecipherable initials behind a medical practitioner’s name and wondered what do they mean?

Decoding Specialists

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Common Acronyms At A Glance• FRACS Fellow of the Royal Australasian College of Surgeons• FRACP Fellow of the Australian College of Physicians•  FRCS Fellow of the Royal College of Surgeons•  FRCP Fellow of the Royal College of Physicians• MRCP Member of the Royal College of Physicians•  MB BS Bachelor of Medicine & Bachelor of Surgery•  MB ChB Same as MB BS but usually originates from UK or NZ•  FRANZCP Fellow of the Royal Australian & New Zealand College of

Psychiatry• MAPsS Member of the Australian Psychological Society•  FAFOM Fellow of the Australasian Faculty of Occupational Medicine•  MPH Master, Public Health 

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Medical Terms and PhrasesMedical Terms Phrases/Meaning

Aetiology of the problem Study of the cause

Asymptomatic No symptoms experienced

Congenital abnormality Existing at birth

Functional No exact cause

Objective clinical findingsThose found on clinical examination of the worker

Paucity of symptoms Very little if any

Soft tissue Muscle injury only

Subjective findingsBased on what the doctor is told by the worker

Symptomatic Symptoms experienced

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Assessment of Soft Tissue Injuries

Limb Injuries Back Injuries Specific Conditions

Specialist

Ligament damage

(eg sprained wrist)

Muscle damage (eg whiplash)

Herniated

disc

Muscle strain

Carpal Tunnel Syndrome

Tennis Elbow

Occupational Physician

Orthopaedic Surgeon * * *

Rehabilitation Physician

General Physician

General Surgeon * * - * -

Rheumatologist

Neurologist - - - -

Neurosurgeon - * * - * *

- not suitable for assessment of this condition

* suitable to assess if surgery is required or has occurred

proficient in assessment of this condition

expert in assessment of this condition

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Support OnlineWhat is Support Online?

• Support Online is a unique and cost-free resource from mlcoa that provides you with immediate access to expert healthcare advice in most specialist fields.

How does Support Online work?

• Any preliminary enquiries that you email to mlcoa via support@mlcoa.com.au regarding a personal injury or related case will be answered within 2 working days of the receipt of your request.

• mlcoa's extensive resources also address more complex matters. We will advise you should the issue be so complicated as to attract a fee or require an extension of response time.

Support Online benefits you through

• Immediate access to medical and research information services• Prompt responses to introductory case queries• Authoritative information from specialist medical and other healthcare experts• Cost-free services in most cases• Convenient email access from your office or home• Improved efficiency of case/claims management• Access to more intricate resources as required

Email Support Online at support@mlcoa.com.au

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Thank you for your attention

Any Questions?

Presentation is Copyright © 2007 MLCOAMelbourne, Victoria