I had a recent experience worth blogging about.
A Human Resources adviser to an employer recommended that I undertake a ‘Fitness for Work’ assessment as an independent medical examiner (IME). Apparently there were concerns about the worker’s rehabilitation progress. The insurer objected, but there are differing accounts as to the basis of the objection. I was not present at the meeting where this proposal was discussed to know first hand what was actually said.
One objection apparently raised was that I might take on a treatment role. The alternative objections were that, as an occupational physician I am not qualified to assess psychological cases, that the insurer saw no reason to revisit liability or the costs of the assessment would be too great.
I want to focus on the issue of IME examiners taking on a treatment role. It is a basic issue where I would have thought the ethics were clear.
An IME shouldn’t take on treatment – but are there exceptions?
In what circumstances can a doctor engaged to conduct an independent medical assessment take on a treatment or management role? What constitutes treatment? Does a recommendation to undertake an exercise programme constitute treatment?
Here is an excerpt from the AMA document on this subject.
5.1 A doctor conducting an independent medical assessment should not provide routine treatment for the examinee. Emergency treatment should only be provided where no reasonable alternative exists and immediate referral is then made to a treating agency or treating doctor for ongoing care.
Here is a link to complete document:
Kim Uildriks, Contract Psychologist to ADF/Medibank Health Solutions recently posted an article on a related topic:
The thrust of the article is that IME assessors should assist workers acutely distressed during an IME assessment. I am surprised there would be any debate about that.
Kim quite reasonably concluded:
To me, as a treatment psychologist, the prospect of not offering support to a client when they are obviously in need seems preposterous. But, could I be wrong? How would you as an IME treat someone in this situation? Would offering assistance really compromise your neutrality?
Apart from emergency treatment, I believe the only acceptable circumstance for an independent doctor to progress to a role to direct or manage treatment (or any of the other functions of a treater such as certification or prescription of medication) would be in a situation where the worker (or their own doctor) specifically requested such a course of action and there were no other practicable options to provide the necessary treatment or management expertise through another practitioner (and then only with consultation with the party that had requested the independent assessment).
While I have conducted thousands of Independent Medical Examinations over my working career, I can recall only handful of cases where I later took on a management or treatment role for the worker. A few years ago I did take on management of a worker who had suffered serious injuries in a fall from a height. I had seen the worker for independent assessments at the request of the worker’s solicitor. The rehabilitation physician managing his case withdrew from practice and asked that I take on a management role as there were no other suitable rehabilitation physicians available in Hobart. I agreed to take on that role after discussion (and informed agreement) with the worker and advising the solicitor about the change in role – explaining that I could no longer be considered ‘independent’ in any later legal proceedings.
In my experience this set of circumstances is very unusual, even in Tasmania where there are limited numbers of specialists.
I am aware that in Tasmania other doctors sometimes take on a management or treatment role after an insurer, lawyer or employer has arranged the appointment. Sometimes the role taken on is only to the extent of making a referral for an exercise programme thought necessary, but in other cases extensive and ongoing treatment has been initiated. I am not aware of what request might have been made of the doctor, but it is clear from discussions I have had with some of these patients I have subsequently seen, in some cases at least, that the doctors involved did not explain to the worker their right to choose any doctor who provides treatment.
I believe it is IME ethics ‘101’ that an IME assessor doesn’t take on treatment except in unusual circumstances, but I am not sure that is universally accepted. Is it an issue in other states? Tasmania is a small jurisdiction with limited medical resources that might be an exception.
I am interested to hear what happens in other states.