Literature Review

Abstract

Do physicians correctly rate permanent impairment in chronic low back pain patients? How accurate and consistent are permanent impairment ratings for low back problems? Very few articles in the medical literature deal with this problem.Clark and Haldeman's 1993 article describes a study on workers' compensation patients with low back pain. This study was done in California, a state that does not use the Guides, but has its own rating system. The article's introduction states, “Two or more examiners consulting on the same injured worker would often submit grossly different findings and conclusions.”Their California study considered 200 consecutive low back pain patient disability rating reports. The authors picked the 42 best (most complete) reports. Multiple physicians reviewed each report and rated each individual's disability. An average of 14 physicians rated each case, with the ratings differing considerably. The difference between the lowest and the highest ratings assigned to the same case averaged 43%. This study was one factor in California revising its impairment rating system.Authors of the studies in West Virginia and Iowa surveyed physicians on their permanent rating practices for chronic low back pain patients. Similar questionnaires were used to assess the habits of physicians in these two states. The Guides was not used exclusively by those surveyed, but most used the Guides at least frequently in their practices.The West Virginia and Iowa study authors reached similar conclusions. They found that the physicians confused the concepts of impairment and disability. Instead of rating impairment solely on medical criteria, physicians admitted that they considered factors such as patient motives, other medical problems, age, education, personality, IQ, and social environment.Widespread differences arise amongst physicians when disability issues are considered in rating the medical impairment of a common patient. The physician's task generally is to rate medical impairment. The Guides' Glossary defines impairment as “the loss, loss of use, or derangement of any body part, system, or function.” It defines disability as “a decrease in, or the loss or absence of, the capacity of an individual to meet personal, social, or occupational demands, or to meet statutory or regulatory requirements.” Disability is typically determined by judges, juries, workers' compensation commissions, and other fact finders. Physicians can improve their role in permanent impairment rating by rating medical impairment and not attempting to factor disability issues into an impairment rating.To further improve the impairment rating process, physicians should document how a rating percentage was derived. When the rating is given, the physician should cite which tables and figures (including page numbers) were used. The discussion should clearly explain the medical basis for the impairment rating. Unfortunately, many reports merely state something like, “the examinee has a 10% permanent to the whole person according to the Guides,” with no elaboration on where in the Guides a reviewer would look to see how the impairment rating was derived.The fourth edition states:For this dispute resolution process to occur, each physician rating the patient must leave a trail that shows how the permanent impairment rating was derived by using the Guides.James B. Talmage, MD