May June Page 3

MERLE JANES, M.D. ^pop SPECIALIZING IN PHYSICAL MEDICINE, PAIN MANAGEMENT & REHABILITATION BOARD CERTIFIED DIPLOMAT OF THE "AMERICAN ACADEMY OF PAIN MANAGEMENT" EMG
Phone: 509-927-4252 FAX: 509-927-4426 23700 EDMONDS WAY EDMONDS, WA 98026

Independent Medical Exam improvement needed.

Intro: IME’s are a fact of life in this industry. Many are poorly-done. How to know which?

The Independent Medical Exam is intended to give a fair, fresh look at a patient’s problem list, without the bias of the patient’s own family doctor, and perhaps to give a new perspective from the input of specialists and sub-specialists.
However, in actual practice it mostly does not work out this way. The IME doctors do have a bias, one that is anti-patient, even hostile, and it is almost always obvious. The IME’s are usually written by doctors who are retired by age or by past malpractice which has denied them the ability to continue in hospital or private practice. For many of these doctors, IME’s are all that they do, and the resultant stultification is obvious when one reads the ‘rubber stamp’ nature of their IME reports. {Oregon has enacted a law that stipulates that any MD or DO doing IME’s must not make over half their annual income at this. The intention of the law is to have younger doctors doing the IME’s, those who continue in actual medical practice and who have a stream of fresh experience every week.} The result of this dependence on IME’s for income makes the IME doctor biased in favor of their employer. They are manifestly not neutral.
In Washington State an additional insidious practice has developed of allowing chiropractors to do IME’s on patients who are being cared for mainly by MD’s. There is a state law specifically prohibiting MD’s and DC’s from critiquing each others’ practice (because their education, training, and experience are so distinct), but this is largely ignored.

There is another glaring deficiency in the everyday IME exam: lack of objective measurement, sloppiness, and corner-cutting. Patients have told me horror stories of the IME doctor being slovenly, openly insulting, slurping coffee or messily devouring a submarine sandwich overflowing with oily onions, while asking the patient a series of questions, often too fast for them to give thoughtful, complete replies. Too many patients have told me these stories for me to dismiss them as fanciful. Just last week a patient told me that, car-door to car-door, he was in and out of the IME in eleven minutes, most of that to fill up paperwork. The IME neurologist said, “I don’t even know why they’ve sent you to me,” and his ‘exam’ consisted of, “stand on your toes. Walk up and down. Squat. OK, you can go back to work now.” The patient’s problem? It had zero to do with low back or legs; he had a shoulder injury. The neurologist’s report was twelve pages long, all cribbed from previous reports and medical records, and the half-page devoted to the actual examination was cut from whole cloth. In other words, the IME neurologist lied, he invented the numbers and data in his report.
IME’s by two or more doctors are often just conducted by or the reports written by just one of the group, then co-signed by the others even though they did no actual individual work at all. The presence of their names, their MD, and their signatures are intended to give gravitas to the final report, but it is a hollow and easily discovered gesture.
Most IME’s have ‘exams’ based entirely on the subjective bias of the doctor, with zero reliance on actual, objective measurements. Instead of measuring grip strength or upper limb strength with dynamometers, for example, which takes several minutes of measuring and recording, they just say, “Squeeze my fingers. Push against me. Now pull against me.” Then they write “hand strength and limb strength 5/5”. Why is this bad? This 5/5 business dates from the 1930’s as a quick way to evaluate polio patients. ‘5’ is normal strength with full range of motion. It was never intended as a system to check normal people without polio. From the point of view of neuroanatomy, for a person to drop one grade of strength, from a ‘5’ to a ‘4’, for instance, this means that they must lose half of their motor units. This is too crude a measurement for most medical situations because injuries almost result in pain, such that the spinal cord limits maximum muscle output even in the face of a maximal mental command to that muscle. Subtle strength differentials between one arm and the other, for example, can lead to correct diagnosis and treatment, but this can only be divined using measuring tools, not the crude “5/5” manual muscle testing.
My take on this subject (from 25 years of reading their reports) is that (a) most IME doctors just don’t know how to use the measuring tools and (b) they’re just too slothful to use them anyway, because accurate, complete measurement of both upper limbs can take twenty minutes and they’d rather just do the manual muscle testing and be done in twenty seconds.
The same can also be said for measuring joint range of motion using goniometers and inclinometers. The expression, “full” range of motion is often seen in IME’s and is a useless and usually incorrect statement. Actual measurement takes skill, experience, and careful attention to detail, all of which appear to be antithetical to most IME doctors, who all seem to be in a big hurry to get through ten ‘exams’ a day and collect their $500 apiece for each one. By their repeated actions year-in and year-out they plainly have zero interest in fairness or accuracy and most often seem clearly to consider themselves ‘hired guns’ of the surety and appear to think the more they sneer at the patient the more they’ll be beloved by who hired them.

Such IME’s are worthless and truly deserving of the IME sobriquet, “Imitation Medical Exam.” How can this situation be corrected?

The doctor(s) doing the exam should not be a ‘career’ IME writer.
The doctor(s) doing the exams should have a regular private practice.
The doctor(s) doing the exams should see several new patients a week at their non-IME office and be thoroughly conversant with active patient management in all phases, including the very difficult task of shepherding an injured patient through therapies of all kinds, and back ‘out’ again, out of therapies to a completed treatment program.
The doctors should correctly use objective measuring instruments such as goniometers, inclinometers, and dynamometers. They must not estimate or guess.
If the IME has more than one doctor, each one needs to do an individual exam and, if required, select one of the group to give a summation at the end of the report which integrates the several report exam findings and conclusions.

Conclusion: Bad IME exams denigrate the patient and surety alike, and waste enormous amounts of money and time. When the IME exams and reports are so clearly phony, and so evidently partisan, this costs everyone millions of dollars annually, as well as lost goodwill, and the human costs associated with poor outcomes due to delayed treatment. Too many people see the surety ‘purchasing’ an IME from ‘reliable IME doctors’ as a quick-and-dirty way to close a claim. Some claim managers think this is a cheap way out. They are wrong.

Good IME exams are possible with existing, low-tech measuring instruments but only if the examiner is trained in their use and does a careful, considered, non-biased exam. Good exams shouldn’t cost more than bad ones, and the cost savings of guiding medical expenditures towards effective treatment should more than make up for any short-term costs.

Sincerely,

Merle Janes, MD

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