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Workers’ Comp and the
Toxicology Independent Medical Exam
(IME)
Brent T. Burton, MD, MPH, FACMT, FAACT
WHAT IS AN IME? • An IME is a medical exam conducted to determine the
cause, extent and medical treatment of a work-related or other injury where liability is at issue.
• An IME is a one-time exam performed by a physician who does not have a treatment relationship with the patient.
• A doctor-patient relationship is not established and medical treatment or advice is precluded (except in the case of
life threatening conditions).
PURPOSE OF THE IME
• Compensability – Work Related? • Apportionment • Impairment Rating • Treatment Appropriateness • Status – Maximum Medical Improvement • Fitness for Duty
CLAIM PROCESS Role of the Toxicology IME
Claim Filed
Insurer Review
Claim Denied Appeal IME Hearing
Claim Pending IME Insurer
Review
Claim Accepted
Medical Treatment IME*
*Impairment Rating *Treatment Issues
IME REFERRAL SOURCES
• Insurance Claim Administrators • Employers or Third Party Administrators • IME Companies • Attorneys • Government Agencies • Attending Physician (Indirect)
WHY PERFORM IME’s?
• Intellectual Challenge • Flexible Schedule • Nobama Care • No Medicare • Simple Billing • Minimal Overhead • Administrative Support • Financial Gain
COMMON EXPOSURES • Inhalation
o RADS, Asthma o Asbestos, Silica o Gases and Vapors
• Metals: Lead, Mercury, Chromium, Arsenic • Pesticides: Organophosphates, Glyphosate, 2,4-D • Sensitizers: Isocyanates, Latex, Mold, Animals • Cancer • Neurologic: Neuropathy, encephalopathy, Parkinson’s • Alcohol & Drug Impairment • Food Poisoning • Fads: SBS, MCS, “Toxic Mold,” Porphyria, HMP/Chelation
IME CHALLENGES • PreDiagnosis • Motivational Factors/Cooperation • Peer Review • Deposition and Hearing Testimony • Attorney Interference
o Coaching o Non-cooperation.
• Records, Questionnaire, Diagnostics o Exam Limits o Observation /Recording
ENVIRONMENT OF BIAS
“The totally biased IME doctors are willing to say whatever they think the people paying them want them to say."
Sharpe Law Firm – Seattle, WA
".......many IME doctors appear to skew their reports in favor of the defense.“
Aaron Larson – Attorneys-USA
“There is nothing independent about it. The insurance company hires a doctor it knows will minimize your injuries.”
Schneider & Madsen Law Firm – Willmar, MN
What attorneys tell their clients:
IME EXAMINER REQUIREMENTS
• State Medical License o Reciprocity not always authorized for IME’s.
• Malpractice Insurance • State Certification as IME Examiner
o Application, CME, Testing o Agree to abide by rules.
IME PROCEDURE • Receive Referral
o Schedule 2 Hour Appointment o Patient (Examinee) Registration o Send out Confirmation w/ Questionnaire o Diagnostic scheduling
• Exam Commencement o Introduction, Purpose and Referral Source o No Doctor Patient Relationship o Format of exam, i.e. H&P, diagnostics. o Release authorizations, if required
Exposure History
• Standard Medical History Format o Supplement with Health Questionnaire o Lifetime chronology o Characterize all past medical encounters
• Symptoms • Diagnoses • Treatment & Response
o Lifestyle/Behavioral characteristics • Tobacco, alcohol, drugs, hobbies, etc.
Exposure History • Focused Work History—Learn the Job!
o Type of workplace o Job description o Use of each substance o Protective equipment o Labels and/or Material Safety Data Sheets
• Are Symptoms Consistent with Exposure? o Character
• Irritation • Intoxication • Toxic Syndrome
o Timing—Relationship to exposure o Duration
MSDS
Material Safety Data Sheet ●Product Name ●Hazardous Ingredients ●Physical Data ●Fire and Explosion Hazards ●Health Hazards ●Reactivity ●Spill Procedures ●Special Protection ●Precautions
Exposure Assessment
• Biological Indicators o DOI lab studies, e.g. CO o Direct measure, e.g. blood lead o Target organ markers, e.g. PFT’s, Immune response.
• Workplace Environment o Industrial Processes o Industrial Hygiene Survey/Workplace sampling o OSHA Inspection/Citations o Site Visit
Objective Data
Analysis of Causation
I. EXPOSURE
II. DISEASE
III. RELATIONSHIP
IV. EXCLUSION OF OTHER CAUSES
• Was there a toxic exposure in this case?
• What evidence supports a diagnosis?
• Did this exposure cause this disease? • General Causation? • Specific Causation?
• Have alternative etiologies been considered?
Association ≠ Causation
Exposure ≠ Disease Pb
Disease ≠ Exposure Mesothelioma
Exposure + Disease ≠ Causation CO
Causation Caveats
Documentation of Disease
• Consistent Symptoms • Objective Findings
• Physical Exam • Diagnostic Studies
• Diagnostic Criteria
Exposure v. Disease Relationship
Valid Exposure-Disease Relationships: n-Hexane v. neuropathy Asbestos v. mesothelioma
Benzene v. AML TDI v. asthma
Invalid Exposure-Disease Relationships: Sick building syndrome Multiple chemical sensitivities Chemically-Induced Porphyria Fibromyalgia
General Causation Has a valid causal relationship been established between exposure and this specific disease?
Exposure v. Disease Relationship
Is there adequate documentation that an exposure of sufficient intensity and duration (i.e., dose) can cause disease or injury in this case?
Specific Causation
New onset? Or exacerbation of preexistent injury/illness?
Dose Response Relationship “Alle Ding' sind Gift, und nichts ohn' Gift; allein die Dosis macht, daß ein Ding kein Gift ist.“
Paracelsus (1493-1541) Father of Modern
Toxicology
(“The dose makes the poison.”)
Alternative Causes
Has a thorough and appropriate differential diagnosis been applied and each potential alternative diagnosis excluded?
Alternative Considerations Sources of common symptoms often attributed to occupational diseases:
Odor Perception Smoking Substance Abuse Infection Allergies Psychological Factors Underlying Medical Conditions
IME REPORT Discussion Format • State conclusions (opinion)
o Avoid hedging or “wiggle words” o “I feel, believe, consider” etc. o “consistent with”
• Characterize exposure. • Medical data that support or refute the proposed diagnosis • Relationship between exposure and proposed diagnosis • Alternative conclusions, i.e. differential diagnosis • Respond to specific “legal” questions posed by requestor
o Medical-Legal Connection
Medical-Legal Connection Work Cause/Contribution
Varies by State Statute
• Proximate Cause, Major Cause, etc. • Medically Stationary, MMI, etc. • Combined Condition (apportionment) • Impairment Rating—e.g. AMA Guidelines
IME REPORT
• Potential Follow-up Requirements o New records for review o Attorney Consultation o Concurrence letters, addendum reports o Deposition – defending the IME report o Hearing -- ALJ’s, attorneys & witnesses