Patrick has kindly provided the comments below on four earlier blog articles I have published:
A Day at the Beach
Barry Gilbert on IME’s
The Law Trumps Health – or so it seems!
What’s It All About, Dr Alfie?
The example of fraud provided by David Cherry is certainly an interesting one that I haven’t encountered before.
Thanks Patrick, I know you will have seen the whole spectrum of issues given the length of time you have been involved in workplace rehabilitation in Tasmania.
As an occupational physician in private medical practice in Hobart, Tasmania - the southernmost state of Australia, I see workers referred by their general practitioners with various types of work-related injuries and diseases. These are mostly musculoskeletal injuries, both of traumatic and gradual onset as well as various associated psychological disorders. With interaction with patients for treatment and providing advice about rehabilitation, I have the opportunity, first-hand, to observe interactions between individual patients and compensation systems. I also conduct independent medical assessments, including impairment assessments for musculoskeletal injuries and asbestos-related disease compensation. This provides another perspective of workers within compensation systems.
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Is there any medical professional prepared to define what “regional pain syndrome” or “complex RPS” really is? Seems to me that it the modern day equivalent of lumbago or tonsillitis (i.e. using a Latin or Greek word to describe a symptom because a genuine diagnosis is too difficult).
Medical diagnosis is a meaningful concept for health professionals as a means of characterising a particular disease or injury and the most appropriate treatment or management pathway. Doctors in training are taught that the history from the patient is the most important aspect of diagnosis, but clinical examination and investigations are important aspects to reach a final diagnosis.
It is like trying to fit the proverbial square peg into a round hole to make normal medical processes fit within the legal framework that defines compensation systems.
Some conditions, like the ones that you mention (CRPS) are particularly difficult within a compensation system framework given the variable clinical and investigation findings, but no clinician would doubt the pain and disability caused a Complex Regional Pain Syndrome when it present with a cold, grossly swollen and discoloured limb that cannot even be touched. The challenge is in the continuum that exists between chronic pain disorders where there are no clear clinical signs or investigation results and the type of case I have referred to above.
I would not accept that doctors are fabricating medical conditions by adding suffixes to Greek or Latin names for body parts. Doctors, Insurers and legislators alike need to cautious about labelling medical conditions that are not well understood as ‘psychosomatic’. Keep in mind diseases like asthma and peptic ulcer that once were considered such diseases without a physical basis. At one stage even typhoid was considered psychosomatic!
We do do need better methods to characterise disease states, particularly chronic pain, but to suggest that a condition cannot be genuine without an Xray or blood test to prove it is overly simplistic.
Yes, i agree there are some injured workers out there who are fraudulant but the vast majority are not. There is always so much focus on the injured worker but there is little if any real oversight on the fraudulent claims management aspect. I am saying this from experience. I have been witness to many of the assessments my husband undertook only to see the examiners are not doing the supposed standardised ROM testing (ch 16 AMA 5) as described, although they are still using the applicable pie charts to allocate % scores and they are stating they have carried out the testing as described when they did not. There is a fundamental flaw in the thinking that allows someone to vary test methodology and to still use a score chart developed to score something on the basis of certain specific criteria. You can’t vary the parameters of a test and allocate scores applicable to a different test. My husband had two assessors an hour apart to test ROM for both shoulders. he has had one operation on the left and four on the right. The doctors performed the testing different to each other and different to what is described in the AMA 5 the result was a difference of 10% Whole person- not 10% difference in scores-10% difference in WPI!! Both doctors signed a statement to verify the tests were carried out in accordance with the Guides knowing they had not. Due to this there was a dispute and it went to the Commission and the same thing happened again. Some doctors are allocating passive or assisted motion a score on the basis of the pie charts in chapter 16 used to score active motion and they are stating the movement was active. One doctor wrote in his certificate “All movements were active” as is determined by the guides. When he was questioned about the fact he directed assistance from the opposite limb and scored it as though it was active motion he responded stating such assistance gave a further degree of “active” motion and he claimed this did not bias the scores! You will understand if someone scores 30 degrees of adduction in almost every test they had done and suddenly they are given a score of 60 degrees adduction for both arms when the fact is they were directed to pull each arm across using the opposite arm that there might actually be some bias attributed to the assistance. 60 degrees of adduction is ten degrees above the point the score chart ends at. ie it is comparable to getting 120% out of 100%- would you accept this doctor’s explanation. In another case the doctor scored someone as 80 degrees of adduction and when reexamined by an appeal member, incidentally by the same doctor who scored the assisted motion in my husband’s case, he was given a score of 50 degrees (not known if this was assisted or not) and the appeal panel determined the 30 degree difference in scores in a test where the range is 50 degrees is “broadly similar”. The IW had been looked at as the one who was inconsistent when it fact the methodology was inconsistent but the appeal panel concluded the IW as inconsistent. Mathematically and scientifically anyone with any sense could work out what had gone on in this case and in the case of my husband but all the complaints we made about my husband’s case were handled as though we were stupid and didn’t understand the guides or what happened during the examination stating basically the assessor has the right to his own opinion- the fact the assessor stated assistance gave a greater degree of active motion and the fact the scores were so exaggerated it proved what we stated we witnessed was not even addressed in response to the complaint. What is your opinion?
In my own case I have substantial evidence in my file notes of how an insurer conspired to deny my treatment by using a certain assessor and in another case how they conspired to use another specific assessor, with their solicitors actually stating the opinion they wanted from him in the referral to him. In the file it notes it is specifically stated they need the IME to get a defense as they had claimed I did not have a work related injury. My file notes state they should settle my claim and my employer’s own high level investigation verified what happened to me and they apologised to me in writing as I was victimised as a “whistle blower” on child protection matters and this IME was after I had been paid for a 26%WPI lump sum! The IME did give the opinion they stated saying I had constitutional agoraphobia of all things! I was a teacher for almost 35 years so I think someone would have noticed if I had agoraphobia before my breakdown!
I could go on and on but I think you would get the point ie there is no means of an injured worker exposing fraudulent behaviours within the management of the system unless they have independent evidence and when there is independent evidence they will have to run the gauntlet and be prepared to be smashed about the head (not literally) and when they fall down they have to be prepared to get up and do it again because those running the system don’t want anyone to expose such things that they have authority over.
This is the type of thing that gives IMEs a bad name when hopefully it is the minority not the majority. The important point is though that there are guides to ensure consistency and when the guides are disregarded in favour of unsupported opinion and arrogance (or whatever it is that some IME’s decide gives them the power to vary the guides) it results in some injured workers being made to look inconsistent when they are not.
Look forward to your opinion on this.