This is Part 2 of a 3 part series of blogs about Independent Medical Examinations (IME’s). This series is written from my perspective as a doctor treating patients covered by workers compensation or motor accident insurance. While all compensation systems are not the same, the issues described seem to occur in all systems to some extent. What is of particular concern to me is that the problems described are generally becoming more wide-spread and some systems that were in the past reasonably supportive, are turning to a more aggressive and confrontational model. Use of IME assessments seems to be a feature of a more aggressive liability-denying approach. This adds an additional negative dimension to those that suffer injuries in the workplace or on our roads
I hear the stories of many people who attend IME assessments. Most people go along expecting a professional, caring approach by the independent doctor (and perhaps even helpful treatment suggestions), but are disappointed by a relatively brief and sometimes frankly cursory interview about a complex many-faceted injury. Some assessors rely on the history taken by another assessor at an earlier assessment. Worse still some assessments are confrontational, described as an ‘interrogation’. Sometimes the person being assessed is only allowed to answer ‘yes’ or ‘no’, when a more detailed answer is necessary for the examiner to understand the situation properly. Some IME assessors use techniques that interfere with proper history taking e.g. some assessors dictate their report during the assessment. While this might be reasonable to record some aspects of the assessment, such as the examination findings, this can be intrusive to a proper interview to obtain the patient’s history especially where there are complex matters to discuss or the person being assessed is nervous or has cognitive problems that affect their ability to remember and logically relate their story.
The prejudices of the IME assessor are sometimes evident. They may appear to assume that the person being assessed is not being truthful or is embellishing their story without any evidence to support that presumption.
True, some IME doctors are respectful and thorough and try to gain a full appreciation of how the injury occurred, what treatment has been provided and the effects of that treatment as well as trying to understand the impact of the injury on all facets of the person’s life. Unfortunately that approach to assessment is becoming less common and seems to be the exception now, rather than the rule.
When it comes to physical examination, again some IME assessors might only conduct a cursory examination, asking the person being assessed only to move their limbs around when a proper assessment of a musculoskeletal injury should involve at least a ‘look, move and feel’ approach taught to doctors. Additional tests of nerve function are often necessary. Assessors should properly measure joint range of motion when impairment assessment requires measurement. Some assessors are reported as not using goniometers, the accepted instrument for that purpose. Worse still some claim to use them in assessments, and record that they have in their report, yet the person being examined is adamant that no such instrument was used. Some IME examiners are reported as having scant regard for normal examination protocols to respect the privacy and dignity of the person being examined.
Similarly with review of investigations, such as scans, IME assessors can sometimes ignore or dismiss such results when the person being assessed has dutifully brought them to the assessment.
There are concerns that some IME assessors impinge on the treating doctor’s role by taking on treatment. Sometimes this boundary is poorly understood by the person being assessed. They believe they are obliged to accept a treatment recommendation or even to actual treatment ordered by the IME assessor. While in rare cases, an IME might ethically take on treatment, this would require a very good reason, such as an absence of available suitable specialists in the same field. This could only be done after agreement with all parties, particularly the patient them self that this is in the best interests of medical treatment.
I have recently had the opportunity to discuss these issues with medical colleagues. Many express concerns about the validity of IME opinions. These concerns were summarised in a discussion paper prepared on behalf of AMA Tasmania as follows:
‘Independent medical assessors often provide opinions outside their area of expertise, are not up to date in their knowledge of current practice or consider only selected information provided by the insurer.
Independent medico-legal reports are often unnecessarily requested during the course of a claim. This leads to confrontation changing the mind-set of the patient to proving their case with detrimental effects on recovery.’
Under workers compensation legislation in Tasmania, the worker’s doctor who writes the certificates (known as the Primary Treating Medical Practitioner or PTMP) is obliged to receive a copy of any IME reports about their patient. I see many such reports. The concerns expressed by the AMA above are borne out in many reports. It is evident that the IME assessor might not have considered all the available medical information. I have seen situations where IME assessors have ignored results of important investigations and have repeated their opinions even when their oversight has been communicated to them.
An important principle is that an IME assessor should take fully into account the treating practitioner’s opinion and the results of available investigations before expressing an opinion, however often it is difficult to get that information to the IME assessor, especially when the information provided to them is controlled by the insurer. At times an IME assessor will express a definite opinion when they have not considered all the available information. In circumstances where all available information is not available, the IME assessor should state that fact and defer expressing an opinion until that information is obtained.
Patients often point out factual errors in the history recorded once they see the IME report about them. Sometimes the error will have little bearing on the accuracy of the final opinion but sometimes critical information is left out or is wrong. Either way such inaccuracies or omissions detract from confidence in the ability of the doctor doing the assessment.
Some IME reports include detailed descriptions of the worker being assessed. While it might be reasonable for the assessor to confirm the identity of the person, there is no justification for the doctor to record detailed descriptions of tattoos, body piercings, hair styles or other distinctive features that could only be relevant to identification for covert surveillance activity. There is no place for an IME assessor to be party to covert surveillance of an injured person. I have heard claims that doctors have been complicit in surveillance activities, but never seen any convincing evidence that this has actually occurred. It is relatively common though for the insurer, having organised the IME assessment, to request surveillance of the person during their travel to and from the IME appointment. There was a case where the person being assessed told me that a team of two surveillance operatives followed the claimant and their spouse interstate to an IME assessment, including following them in public places and in a restaurant while they ate their meals.
While the approach taken by an IME assessor can affect the validity of the assessment, the real issue is whether IME assessment is necessary at all, at least in its current form. The IME role, as currently promoted by an ever-increasing number of insurers is based on the need to find evidence to deny liability, reject approval for treatment recommended by treating doctors or identify extraneous issues that might help the insurer deny liability.
The problem, even with a professional IME assessment is that it sets the scene for confrontation and disagreement, rather than co-operative problem-solving. If the IME assessor raises issues of causation, the response from the person being assessed is to assume an attack on their honesty and integrity. This type of attack is vigorously defended by most ‘normal’ people and leads to a legal focus which doesn’t assist recovery. An unprofessional or invalid assessment is far worse and might deny or significantly delay reasonable and necessary treatment with the result that psychological consequences escalate, chronic pain becomes entrenched and the injury might never resolve.
In the 3rd and final blog about IME assessments I will discuss what better approaches there might be. How can we ensure that only competent impartial doctors conduct assessments that are truly necessary. A WorkCover Victim’s Diary promotes ‘Purging Rogue IME’s’ from the system. This might be an appropriate objective, but how is that to be achieved? Who judges who are ‘rogues’ and who aren’t? How can insurers, or solicitors for injured workers for that matter, be prevented from selecting IME assessors who will provide opinions to suit their purposes?
See part 3 for some answers!