I know this stuff about definitions and standards is boring, but I need to set this out so you can make sense of what I plan to say about IME’s in the blogs to follow. So please bear with me. Parts 2 & 3 of this blog series will be much more interesting, I promise.
IME is an acronym for Independent Medical Examination (or Examiner)
According to WorkCover NSW:
‘Independent medical examiners are registered medical practitioners who provide impartial medical assessments’
According to WorkSafe Victoria the role:
‘….is to review your medical condition and/or treatment and provide WorkSafe Agents and self-insurers with an independent medical opinion about your injury or illness. They do not provide you with treatment’
According to WorkSafe Victoria IME assessments can include assessments by physiotherapists, psychologists, osteopaths, chiropractors or dentists as well as assessments by medical practitioners.
The operative word is ‘independent’, i.e. an opinion is obtained that is independent or impartial, but from whose perspective is not made explicit. Is the term independence meant to reflect independence from the bias or advocacy that might be inherent in the relationship between a doctor and their patient or does independence refer to independence from the party requesting (and paying for) the examination? This is usually not spelled out, but the former meaning is suggested by statement from WorkCover authorities that Independent Medical Examiners do not provide treatment i.e. they do not form a patient/doctor relationship.
While the government workers compensation definitions above suggest that IME assessments are those obtained by an insurer or WorkSafe agent, a worker or their legal representative or any interested party including an employer can obtain an IME assessment.
A related term is medico-legal assessment, but such a term without any reference to independence, can encompass any type of medical assessment whether conducted by an independent practitioner or a medico-legal report obtained from a treating doctor.
IME assessors are obliged to be courteous and treat the person being assessed in accordance with accepted ethical principles, but there is no ‘duty of care’ to the person being assessed. An opinion can be expressed about diagnosis and treatment needs, but usually there is no legal recourse available if the opinion is incorrect. That responsibility falls to the treating doctor.
At all times, practitioners should treat the examinee with dignity and respect. In order to avoid appearing insensitive, rude, or abrupt in their manner or rough in their examination, practitioners are advised to give particular attention to identifying the examinee’s concerns, and to adequately explain the reasons for the examination. Adequate time should be allowed for the consultation to enable a complete assessment to be carried out.
The NSW Medical Board provides the following guidelines (1996):
1. At all times, the practitioner should communicate with the examinee in language that they can understand.
2. The examinee has the option of having an accompanying person present during the history and/or the examination. This should be explained to the examinee when the interview is being scheduled. The role of the accompanying person is to support the examinee, but not to answer questions or contribute to the assessment. However, should the examinee have an intellectual or speech difficulty, it is appropriate for the accompanying person to assist in the communication between practitioner and examinee.
3. A professional interpreter should be used where the examinee has a difficulty with spoken English. Interpretation should not be provided by a support person or member of the examinee’s family.
4. The practitioner should not make any unnecessary personal remarks, especially when the consultation involves an intimate examination.
5. The practitioner should be aware of differing cultural sensitivities, especially when conducting an intimate examination.
6. Some practitioners choose to video or audio record the examination. The reason for this should be clearly explained to the examinee and consent should be obtained in advance.
7. The practitioner should not offer any opinion to the examinee on their claim or medico-legal circumstances.
8. The practitioner should not offer any opinion on the examinee’s medical or surgical management by other practitioners.
9. In the majority of cases it is appropriate to advise the examinee of an incidental clinical finding which has been identified by the examining practitioner. There may be some situations where it is preferable to notify the examinee’s treating practitioner.
10. It is not appropriate for the practitioner to undertake any form of treatment in relation to the examinee.
1. The practitioner should properly introduce himself or herself and explain his or her specialty field of medicine in language which the examinee can understand.
2. The practitioner should explain the purpose and nature of the consultation and examination and that it is not the practitioner’s role to treat the examinee.
3. The practitioner should explain that his or her role is that of an independent reviewer who is providing an impartial opinion for use in a court or before another decision making body and that there are limitations on the confidentiality of the assessment. The practitioner should be aware that the patient may believe that they are not independent, but are working for the third party.
1. The practitioner should limit their questions to matters that are relevant to the purpose of the assessment, prefacing personal questions with an explanation as to why they are necessary.
2. The examinee should be given an opportunity to provide information that they believe may be relevant to the assessment.
THE PHYSICAL EXAMINATION
1. It is essential that prior to commencing an examination, the practitioner explains which part of the body is to be examined, why it is to be examined, and what the examination entails, including the extent to which undressing is required. The position of the practitioner during the examination should also be explained, particularly when the practitioner will be standing behind the examinee.
2. The examinee’s modesty should be preserved by;
- the provision of a screen behind which the examinee can undress and dress,
- the practitioner excusing himself or herself from the consulting room whilst the examinee is undressing,
- the provision of a gown or sheet
3. The practitioner should examine the examinee in privacy, unless the examinee has brought a support person to be with them at that time, although the practitioner may choose to have a chaperone present during the examination.
4. Examination should be limited to the area relevant to the examinee’s problem. It is inappropriate for a practitioner to examine any part of the body without the examinee’s consent. This may limit the scope of the practitioner’s examination and subsequent report.
5. If an intimate examination is warranted, the reasons and nature of the examination must be carefully explained to the examinee, and the examinee’s permission obtained. This should be noted in the report.
1. The practitioner should ensure that their report contains both the examinee’s history and examination findings and that it notes all diagnostic possibilities. Any limitations to a full assessment should be noted.
2. The report should be impartial and unbiased, and reflect the practitioner’s consideration of the available opinions of other practitioners and health professionals who have assessed, treated or provided reports on the examinee in the past.
3. The report should be completed within the timeframe requested by the third party unless there are foreseeable delays or the deadline is unreasonable, in which case practitioner should negotiate a new timeframe.
4. The report should set out the material relied upon and any assumptions made.
5. The report should be comprehensible, easy to read and explain medical terminology.
6. The practitioner should be aware of the risks inherent in utilising his or her previous reports as the basis of a subsequent report without further review of the examinee.
I hope this information helps when discussing the issues that arise in the real world of IME assessment – the subject of Part 2, coming soon.