Independent Medical Evaluation Research Articles

B - 127 Equivalence of In-Person and Remotely Administered Performance Validity Tests: Evidence from a Forensic Sample

Abstract Objective While neuropsychologists are increasingly recognizing the importance of tele-neuropsychology (teleNP), existing research has not comprehensively explored equivalency of commonly used performance validity tests (PVTs) and symptom validity tests (SVTs) across in-person and remote administration. This is despite the fact that such measures are a crucial component of any neuropsychological assessment battery and are, as such, considered medically necessary. Furthermore, the existing teleNP research base is primarily limited to clinical and other non-forensic samples, with limited applicability to forensic teleNP evaluations. The current study examined the equivalency of in-person and remote administration of widely used PVTs and SVTs in a forensic sample. Method Archival data between July 2021 and December 2023 were collected from a private practice setting in which board-certified neuropsychologists (ABPP/ABCN) conducted independent medical evaluations (IMEs) in controlled settings with utilization of an on-site proctor. Mean PVT and SVT scores across in-person and remote evaluations were compared. Results All included PVTs and SVTs (TOMM, DCT, WAIS-IV RDS, Word Choice, WMT, MENT, MSVT, IOP-29, SIMS, MMPI-2-RF scales) showed mean equivalency across in-person and remote administration (p > 0.05). Conclusions Findings provide preliminary support for the adaptation of both PVTs and SVTs for teleNP. Implications are present for forensic and clinical practice, although future research should continue to establish preliminary trends.

Prescribing Justice: A Close Examination of Physicians Acting As Expert Witnesses in Saudi Arabia.

An expert witness is a person who provides testimony on issues that the court finds to be outside the scope of their expertise and experience. Any physician who has performed an independent medical evaluation or written medical records can and should expect to be requested as an expert witness. Medical malpractice, workers' compensation, and personal injury are the most prominent areas where medical expert witnesses participate and provide opinions and testimony. To our knowledge, this is the first study to be conducted in Saudi Arabia on physicians acting as expert witnesses. This observational descriptive cross-sectional study conducted in Saudi Arabia from November 2022 to July 2023 aimed to assess physicians' experiences, education, training, willingness, self-competency, attitude, and perception as expert witnesses. The study population consisted of physicians working in Saudi Arabia, with at least a specialist level of professional expertise. Participants completed a self-administered online survey, utilizing a researcher-designed questionnaire. In total, 417 participants, with males comprising 51.3% of the sample, responded to the survey. More than half of the physicians (58.3%) had never produced a medical report for the court. Among those who had, the majority had done so one to twice. Similarly, the majority had never testified in court (77.5%), with only a small percentage having done so once or twice. Approximately 80% of participants had no prior education or training as expert witnesses, but among those who did, courses and workshops were the most common forms of education or training. Most participants expressed interest in learning or training for this role (69.1%) and were willing to provide medical reports or court testimony (73.9%). However, half of the participants did not feel competent in writing a medical report for the court, and more than half lacked confidence in giving testimony. The findings highlight the need for increased engagement, education, and training among physicians, particularly early and mid-career professionals, to enhance their confidence and competence as expert witnesses and ensure ethical practices in the medicolegal domain in Saudi Arabia.

A Primer for Workers' Compensation

Abstract Background Context: A physician's role within a workers' compensation injury extends far beyond just evaluation and treatment with several socioeconomic and psychological factors at play when compared to similar injuries occurring outside of the workplace. Although workers' compensation statutes vary among states, all have several basic features with the overall goal of returning the injured worker to maximal function in the shortest time period, with the least residual disability and shortest time away from work. Purpose: To help physicians unfamiliar with the workers' compensation process accomplish these goals. Study Design: Review. Methods: Educational review. Results: The streamlined review addresses the topics of 1) Why is Workers' Compensation Necessary? 2) What does Workers' Compensation Cover? 3) Progression following Work Injury 4) Impairment and Maximum Medical Improvement (MMI), including how to use the 6th edition of American Medical Association's (AMA) Guides, 5) Completion of Work Injury Claim after Impairment Rating, 6) Independent Medical Evaluation, and 7) Causation. Conclusions: In the ‘no-fault’ workers' compensation system, physicians play a key role is progressing the claim along and, more importantly, getting the injured worker back to work as soon as safely possible. Physicians should remain familiar with the workers' compensation process, along with how to properly utilize the AMA Guides.

Q&A: Independent Medical Evaluation vs Medical Consultation

Q&A: Independent Medical Evaluation vs Medical Consultation

Q&A: Retention of Records for Independent Medical Evaluations

Q&A: Retention of Records for Independent Medical Evaluations

What is the effect of independent medical evaluation on days on sickness benefits for long-term sick listed employees in Norway? A pragmatic randomised controlled trial, the NIME-trial

BackgroundIndependent medical evaluations are used to evaluate degree and reason for work disability, uncertainty around the functional status, and/or the employee’s rehabilitation potential in several jurisdictions, but not in Norway. The main aim of this trial was to test the return to work effect of independent medical evaluation (IME) (summoning and consultation) compared to treatment as usual (TAU) in Norway, for workers who have been on continuous sick leave for 6 months.MethodsThis was a pragmatic randomised controlled trial including all employees aged 18–65 years, sick-listed by their general practitioner and on full or partial sick leave for the past 26 weeks in Hordaland County, Norway in 2015/16. Trial candidates were drawn from a central register at the Norwegian Labour and Welfare Administration at 22 weeks of sick leave. Pregnant women, individuals with cancer or dementia diagnoses, those with secret address, employed by NAV or sick listed by the specialist health services were excluded. Separate regression analyses were conducted to investigate the “intention-to-treat” and “treatment on the treated” effects, using the ordinary least squares and instrumental variable methods, respectively.ResultsAfter exemption based on predefined exclusion criteria, 5888 individuals were randomised to either IME (n = 2616) or TAU (n = 2599). The final intervention group constitutes 1698 individuals, of which 937 attended the IME consultation. No baseline differences were found between the IME and TAU group regarding gender, age, and previous sick leave. Individuals attending the IME were older than those who cancelled the appointment ((47/45), p = 0.006) and those who did not show up without cancelling ((47/42), p < 0.001). Mainly the IME physician agreed with the regular GP upon level of sick leave. In cases with different assessments, the difference tended to be towards a lower sick leave level. There were no intention to treat or treatment on the treated effect on days of sick leave after randomisation during follow up.ConclusionsOverall, the analyses showed no effect of IME on changes in sick leave for sick listed employees. This result was consistent for those who were offered an IME consultation (intention to treat) and those who undertook an IME consultation (treatment on the treated).Trial registrationClinicalTirals.gov trial number NCT02524392 first registration 14.08.2015.

Ineffective Communication: The Uninformed Injured Worker.

Effective communication has been demonstrated to impact patient health outcomes, specifically in improving symptom resolution, safety, function, and emotional well-being, and to lower malpractice claims. I hypothesized that the communication process with patients with Workers' Compensation is inadequate. Prospectively, claimants presenting for an independent medical evaluation or an impairment rating were assessed concerning the education that they received with regard to their claim. Basic principles were based on the Utah Labor Commission Employee's Guide to Workers' Compensation and an employee information sheet. There were 556 consecutive claimants assessed. None of the participants expressed any familiarity with the employee information sheet. Although there was a mean of 12 months since the date of claim to the evaluation, 536 participants (96.4%) were effectively unaware of the principles surrounding their claim; of these participants, 6 had attorneys and 23 had prior industrial claims. Of the 3.6% of participants who had received the State Employee Guide, 5 had a prior evaluation with the medical director of the Labor Commission, 6 had located the information online, and 9 had been provided information by their nurse-case manager. Even with this information, the context or importance of the information was not well understood. There were 16.4% of participants who were aware of the mileage compensation. Two claimants were aware that the insurer, not the employer, was responsible for managing the claim, 2 claimants were aware that their claim was open for life, and 1 claimant was aware that claimants could change physicians. Workers' Compensation programs were designed to expedite care and treatment while decreasing the adversarial environment for workplace injuries. Yet delays and confrontational events continue to be experienced by the injured worker. This often results in the impression that workplace injuries have worse outcomes for the same diagnosis. The lack of effective education with regard to the rights and responsibilities of the claimant may also lead to this poorer outcome. Given studies showing the benefits of patient education in preventing malpractice claims and improving health-care outcomes, it is suggested that improved patient education for the injured worker is warranted and may lead to improved outcomes with diminished adversarial events.

Q&amp;A: Rating an Adductor Longus Tendon Tear

Q&amp;A: Rating an Adductor Longus Tendon Tear

Virtual Medical and Impairment Assessments

Abstract Virtual independent medical evaluations (IMEs) have become and are likely to remain common even after the coronavirus disease 2019 (COVID-19) pandemic ends, but virtual health care and virtual examinations are not simply a matter of moving to a new platform—rather, they require a transformation that affects all stakeholders. Innovative solutions necessitated by virtual IMEs potentially can improve both quality and efficiency. The American Medical Association (AMA) defines telemedicine as health-related services that are synchronous and asynchronous and include a variety of tools and platforms that allow clinicians to connect with one another and patients (a box provides information about AMA's ongoing telehealth initiative). Physicians who plan to perform virtual evaluations must have the appropriate policies, procedures, and security in place; resources are available from the AMA Guides series of publications. Each component of the virtual IME, including each data element, should be assessed to determine best practices and how to use virtual technologies successfully. The credibility of virtual IMEs may hinge on the examiner's ability to explain both what was done and why it was as efficacious as an in-person alternative or perhaps as useful as any other alternative under the circumstances. One challenge is to master the tools used in virtual IMEs and another is to obtain stakeholders' acceptance of the virtual process, but this will come with time, experience, and effective physician performance.

Fundamental Principles of Independent Medical Examination

Abstract An independent medical evaluation (IME) is a specialized examination or evaluation best performed by a physician who has special training and experience in assessing issues unique to an IME. IMEs must be independent, and opinions should be consistent and impartial and based on evidence-based medicine. An IME includes the essential elements of a medical assessment, including a history, a physical examination (usually), and review of records and studies, followed by clinical impressions or diagnoses, and then by recommendations. The medical assessment may include other practitioners, eg, psychologists and chiropractors. Depending on the referral request, the IME typically discusses disability (the definition depends on the local jurisdiction) based on deficits in the person's activities of daily living. In the IME, the evaluator may be asked to consider claims issues that include causation, apportionment, impairment, work ability, appropriateness, and costs of medical care and/or future needs. The physician who performs the examination does not provide care to the individual and provides medical opinions about issues associated with the case. Impartiality, objectivity, and an understanding of medicolegal issues are required of the evaluator. IME reports are not confidential and likely will be read by many stakeholders in a claim. Accordingly, nonmedical personnel should find it easy to read and understand the IME.

Independent medical evaluation of general practitioners’ follow-up of sick-listed patients: a cross-sectional study in Norway

ObjectivesThe study was designed to examine the sufficiency of general practitioners’ (GPs) follow-up of patients on sick leave, assessed by independent medical evaluators.DesignCross-sectional studySettingPrimary health care in the Western part...

Exaggerated Functional Impairment due to Malingered Neurocognitive Dysfunction Following Mild Traumatic Brain Injury.

Functional impairment associated with Neurocognitive Disorder is often claimed in medico-legal settings after mild Traumatic Brain Injury (mTBI). This case-control study examined self-reported functional impairment and the plausibility of chronic disability claims following uncomplicated mTBI. Independent Medical Evaluations included a battery of performance and symptom validity tests, along with self-reports of physical or emotional complaints and functional impairment. Slick and colleagues' (Slick, D. J., Sherman, E. M., & Iverson, G. L. (1999). Diagnostic criteria for malingered neurocognitive dysfunction: Proposed standards for clinical practice and research. The Clinical Neuropsychologist, 13, 545-561.) criteria ruled out probable malingering in 21 mTBI cases without psychiatric comorbidity and their self-reports were compared to those of seven non-malingering cases with a psychiatric comorbidity, 17 who were probable malingerers, and 31 orthopedic pain sufferers. Coherence Analysis of medical documentation corroborated assignment of mTBI cases to non-malingering versus probable malingering groups. Probable malingerers reported more postconcussion symptoms than non-malingerers (d = 0.79) but they did not differ significantly on tests of neurocognitive performance. Probable malingerers and orthopedic pain patients gave significantly higher ratings of functional impairment (d = 1.28 and 1.26) than non-malingerers. Orthopedic pain patients reported more disability due to pain than non-malingerers (d = 1.03), but pain catastrophizing was rated more highly by the probable malingerers (d = 1.21) as well as by the orthopedic pain patients (d = 0.98). The non-malingerers reported lower emotional distress than the other three groups, but only the probable malingerers reported elevated depression symptoms compared to the non-malingerers (d = 1.01). The combined evaluation of performance validity, function, and coherence analysis would appear to enhance the difficult clinical evaluation of postconcussion symptoms in the medical-legal setting.

Independent Medical Evaluation: A Practical Guide.

Independent Medical Evaluation: A Practical Guide.

Independent medical evaluation for sick-listed patients: a focus group study of GPs\xb4 expectations and experiences

BackgroundNorwegian general practitioners (GPs) are important stakeholders because they manage 80% of people on long-term sick-leave. Independent medical evaluation (IME) for long-term sick-listed patients is being evaluated in a large randomized controlled trial in one county in Norway in an effort to lower the national sick-leave rate (the NIME trial: Effect Evaluation of IME in Norway). The aim of the current study was to explore GPs’ expectations of and experiences with IMEs.MethodsWe conducted three focus group interviews with a convenience sample of 14 GPs who had had 2–9 (mean 5) of their long-term sick-listed patients summoned to an IME. We asked them to recollect and describe their concrete expectations of and experiences with patients assigned to an IME. Systematic text condensation, a method for thematic cross-case analysis, was applied for analysis.ResultsTo care for and to reassure their assigned sick-listed patients, the participants had spent time and applied different strategies before their patients had attended an IME. The participants welcomed a second opinion from an experienced GP colleague as a way of obtaining constructive advice for further sick-leave measures and/or medical advice. However, they mainly described the IME reports in negative terms, as these were either too categorical or provided unusable advice for further follow-up of their sick-listed patients. The participants did not agree with the proposed routine use of IMEs but instead suggested that GPs should be able to select particularly challenging sick-listed patients for an IME, which should be performed by a peer.ConclusionOur participants showed positive attitudes towards second opinions but found the regular IMEs to be unsuitable. The participants did however welcome IMEs if they themselves could select particularly challenging patients for a mandatory second opinion by a peer but emphasized that IME-doctors should not be able to overrule a GP’s sick-leave recommendation. These findings, together with other evaluations, will serve as a basis for the Norwegian government’s decision on whether or not to implement IMEs for long-term sick-listed patients.Trial registrationClinicalTrials.gov NCT02524392. Registered 23 June, 2015.

Scoping review of claimants' experiences within Australian workers' compensation systems.

Objective The aim of this scoping review was to map the literature on the lived experiences of injured workers in Australia in order to better understand the factors that inhibit the transition back to work and improved health. The ultimate aim of the study was to identify areas for further research into workers' compensation systems and practices that are associated with improved occupational rehabilitation outcomes. Methods PubMed, ProQuest, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for eligible articles published in English in peer-reviewed journals from 2001 to 2017. Narrative data synthesis was used to analyse the data collected from included articles. Results Twelve articles examining injured workers' experiences within Australian workers' compensation systems were identified. Injured workers reported similar experiences across states and territories in Australia. Four common themes and three subthemes were noted, namely: (1) relationships and interactions; (2) injured workers' perceptions (subthemes: mental health effects, social effects and financial effects); (3) the workers' compensation process; and (4) independent medical evaluations. Conclusions There are common difficulties that injured workers experience within Australian workers' compensation systems that are reported to impede rehabilitation and return to work. A less harmful, more cooperative approach to worker rehabilitation and compensation is needed. What is known about the topic? Different workers' compensation systems exist throughout Australia. Little is known about injured workers' perceptions of their experiences within these systems in Australia and whether these experiences are similar or different across systems. What does this paper add? This scoping review synthesises available evidence showing that injured workers report negative experiences of workers' compensation systems, and that this experience is similar across the different systems. This review also identified a clear need for future research on workers' compensation systems in order to promote evidence-based approaches to best support the occupational rehabilitation of injured workers. What are the implications for practitioners? Evidence suggests a more holistic, biopsychosocial approach is required by practitioners when facilitating an injured worker's recovery and return to work. This approach is also vital when considering legislative reforms, such as workers' compensation systems, processes and practices.

Sick-listed workers’ expectations about and experiences with independent medical evaluation: a qualitative interview study from Norway

Purpose: To reduce the country’s sick leave rate, Norwegian politicians have suggested independent medical evaluations (IMEs) for sick-listed workers. IME was tested in a large, randomized controlled trial in one Norwegian county (Evaluation of IME in Norway, or ‘the NIME trial’). The current study´s aim was to explore sick-listed workers’ expectations about and experiences with participating in an IME.Material and methods: Nine individual semi-structured telephone interviews were conducted. Our convenience sample included six women and three men, aged 35–59 years, who had diverse medical reasons for being on sick leave. Systematic text condensation was used for analysis.Results: The participants questioned both the IME purpose and timing, but felt a moral obligation to participate. Inadequate information provided by their general practitioner (GP) to the IME doctor was considered burdensome by several participants. However, most participants appreciated the IME as a positive discussion, even if they did not feel it had any impact on their follow-up or return-to-work process.Conclusions: According to the sick-listed workers the IMEs were administered too late and disturbed already initiated treatment processes and return to work efforts. Still, the consultation with the IME doctor was rated as a positive encounter, contrary to their expectations. Our results diverge from findings in other countries where experiences with IME consultations have been reported as predominantly negative. These findings, along with additional, upcoming evaluations, will serve as a basis for the Norwegian government’s decision about whether to implement IMEs on a regular basis.Key points Independent medical evaluations for sick-listed workers has been tested out in a large Norwegian RCT and will be evaluated through qualitative interviews with participating stakeholders and by assessing the effects on RTW and costs/benefits. In this study, we explored sick-listed workers’ expectations about and experiences with participating in an IME. • Participants questioned both the IME purpose and timing, but felt a moral obligation to participate. • Inadequate information provided by their general practitioner (GP) to the IME doctor was considered burdensome by several participants • Sick-listed workers appreciated the IME as a positive discussion, even if they did not feel it had any impact on their follow-up or return-to-work process.

Independent medical evaluation for sick-listed workers in Norway: A focus group study of the experience of IME doctors.

Norwegian politicians have proposed the use of an independent medical evaluation (IME) as a possible solution for reducing long-term sick leave. The use of an IME implies that a new doctor interferes in the relationship between sick-listed workers and their general practitioner (GP). The aim of the current study was to explore experiences of IME doctors from an ongoing randomized controlled trial (the NIME trial evaluating the effect of IME in Norway). Two focus group interviews were conducted with eight of the nine IME doctors employed in the NIME trial. The discussions were audio-taped and transcribed. Systematic text condensation was used for analysis. The participants reported that the IME provides important second opinions, which they felt empowered the sick-listed workers and provided new insights into their condition. Beneficial IME working conditions and enhanced insight into different sick leave measures were crucial to this perceived usefulness. Some of the participants expressed disappointment with GPs acting as passive conductors and struggled to provide feedback politely. Some adjustments were proposed as necessary for the IME to be implemented nationwide. The participants seemed to have gained a different stakeholder identity by sometimes seeing GPs, their peers, as obstacles to return to work and welcomed the use of IME on a regular basis.

Independent Medical Evaluation Best Practices

Abstract The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, states that an independent medical evaluation (IME) usually is a “one-time evaluation performed by an independent medical examiner who is not treating the patient or claimant, to answer questions posed by the party requesting the IME.” Evaluators must adhere to best practice standards and must know that these standards may change over time and must meet the needs of the relevant jurisdiction. IMEs take place in several arenas, including automobile casualty, workers’ compensation, personal injury, medical malpractice, and long-term disability and differ from traditional clinical evaluations. The evaluating physician must be independent and has no (or only a limited) physician–patient relationship. The qualifications required of an IME examiner vary by arena, jurisdiction, and issues. Medical evaluators should be board certified and can obtain a special credential from, eg, the American Board of Independent Medical Examiners or the International Association of Independent Medical Evaluators. In addition, evaluators should have demonstrated abilities in report writing and court testimony, and a section of this article provides a general outline of the topics that should be covered in a thorough report. Quality IME reports are the result of thoughtful, thorough evaluations performed by physicians who have knowledge, skills, and experience in both clinical medicine and the assessment of medicolegal issues.

Protocol for the effect evaluation of independent medical evaluation after six months sick leave: a randomized controlled trial of independent medical evaluation versus treatment as usual in Norway

BackgroundIt has been discussed whether the relationship between a patient on sick leave and his/her general practitioner (GP) is too close, as this may hinder the GP’s objective evaluation of need for sick leave. Independent medical evaluation involves an independent physician consulting the patient. This could lead to new perspectives on sick leave and how to follow-up the patient.Methods/designThe current study is a randomized controlled trial in a Norwegian primary care context, involving an effect evaluation, a cost/benefit analysis, and a qualitative evaluation. Independent medical evaluation will be compared to treatment as usual, i.e., the physicians’ and social insurance agencies’ current management of long-term sick-listed patients. Individuals aged 18–65 years, sick listed by their GP and on full or partial sick leave for the past 6 months in Hordaland county will be included. Exclusion criteria are pregnancy, cancer, dementia or an ICD-10 diagnosis. A total sample of 3800 will be randomly assigned to either independent medical evaluation or treatment as usual. Official register data will be used to measure the primary outcome; change in sickness benefits at 7, 9 and 12 months. Sick listed in other counties will serve as a second control group, if appropriate under the “common trend” assumption.DiscussionThe Norwegian effect evaluation of independent medical evaluation after 6 months sick leave is a large randomized controlled trial, and the first of its kind, to evaluate this type of intervention as a means of getting people back to work after long-term sickness absence.Trial registrationClinicalTrials.gov NCT02524392. Registered June 23, 2015.

Factors associated with the duration of disability benefits claims among Canadian workers: a retrospective cohort study.

Disability insurance protects workers from total loss of income in case of a disabling injury or illness by providing wage-replacement benefits. To better inform early identification of claims at risk of prolonged recovery, we explored predictors of the duration of disability benefits claims. We conducted a retrospective cohort study using claims data provided by SSQ Life Insurance Company Inc., a private Canadian disability insurer. We examined all claims SSQ approved for short- and long-term disability benefits from Jan. 1, 2007, to Mar. 31, 2014, and evaluated the association between 9 variables and duration of short- and long-term disability benefits using Cox proportional hazards regression analyses. For both short- (n = 70 776) and long-term disability (n = 22 205) claims, and across all disorders, older age, female sex, heavy job demands, presence of comorbidity, attending an independent medical evaluation, receipt of rehabilitation therapy and longer time to claim approval were associated with longer claim duration. Higher predisability salary was associated with longer short-term disability claim duration. Quebec residency was associated with longer short-term disability claim duration among workers with psychological disorders, but shorter short-term disability claim duration among those with musculoskeletal complaints and other illnesses. For long-term disability claims, however, residing in Quebec was associated with shorter claim duration, although the size of the association differed across clinical conditions. The factors we found to be associated with the duration of short- and long-term disability claims may be helpful to identify claims at risk of prolonged recovery. Our study has limitations, however, and well-designed prospective studies are needed to confirm our findings and identify other promising predictors.