Depending on one’s definition of disability, between
thirty-five and forty-six million Americans can be labeled as disabled.
Unlike other human conditions such as poverty, gender, childhood,
old age, and race, the definition of disability and the determination
of who is disabled continue to challenge governments and adjudicating
bodies. Thus, the definitions of disability expand and contract
more along political and ideological lines than according to any
clear physical determinations. Since there is no standardized or generally
accepted definition, calculating the cost of disability is difficult.
If the costs of time lost from work, medical care, legal services, and
earning replacements are summed, the estimated cost of disability
in the United States in 1980 was $177 billion, or approximately 6.5% of
the gross domestic product1.
Obviously, disability management represents an area of medicine
that has a large financial impact on society. It is only in recent
times that disability and impairment have been accorded legal status.
Despite the large expenditures of money, time, personnel, and resources, there
is no single comprehensive compendium of information on disability,
the role of physicians in diagnosing and quantifying impairment,
the role of nonmedical professionals (most notably lawyers) in translating
medically derived impairment into legally allowable disability for
financial reimbursements, or the social and legal constructs upon
which disability determination is to be based. Impairment and disability
evaluations encompass medical and nonmedical aspects of injuries
and illnesses and are effectively accomplished only when both components are
properly addressed. These evaluations are often completed by a physician
not involved in the patient’s care through a process called
an independent medical evaluation, or IME.
Physicians are trained to assemble and analyze medical information and
to communicate with each other within a framework of established medical
diagnostic criteria and generally accepted medical principles and
practices. This highly technical and specialized medical language
must be translated for communication with nonmedical users of medical
information. In addition, the legal system has its own highly specialized
language. Definitions of the same word may be different for each
party. Therefore, physicians conducting independent medical examinations
must become more than casually acquainted with the specific provisions
and procedures of the employment and Workers’ Compensation
laws and regulations in the states where they practice, the Social
Security Act, the Americans with Disabilities Act, the Family and
Medical Leave Act, and the regulations published by the federal
agencies administering these statutes.
Physicians are often asked to provide a report describing the
functional loss resulting from a personal injury or an industrial
accident. A paradox is created by this legal request because the
rating of functional impairment is, at best, an inexact science2-4. Furthermore, the American Medical
Association Guides to the Evaluation of Permanent Impairment, Fifth
Edition5 (the AMA Guides),
states that "the Guides are not intended
to be used for direct estimates of work disability. Impairment percentages
derived according to the Guides criteria do not
measure work disabilities. Therefore, it is inappropriate to use
the Guides’ criteria or ratings to make
direct estimates of work disability." Yet, often the impairment-of-function rating
is used by the legal system to provide a monetary award to a patient
on the basis of a perceived disability. As I already stated, disability
evaluations encompass both medical and nonmedical aspects of functional
loss and are only effective when all components are properly managed
and considered. Unfortunately, this conversion of impairment to
work disability can lead to an adversarial situation with potential
for abuse and for exploitation of physicians. Parties may enter into
litigation in an attempt to increase the rating, and the physician
may be drawn unwittingly into the fray between the warring adversaries.
It is essential that physicians understand the principles and process
of impairment evaluation if they are to provide effective assessment
services, which play a role in determining a financial award to
a claimant. In an effort to employ a uniform approach on the basis
of current science and medical consensus, physicians worldwide use the AMA
Guides to estimate permanent impairment of adults. A survey
completed in 1999 indicated that the AMA Guides are
currently used or referenced as the standard in awarding Workers’ Compensation
in forty of fifty-one jurisdictions in the United States (the fifty
states and the District of Columbia)5.
Precise definitions, communication, and role awareness are essential
parts of the independent medical examination.
Disability arises out of an individual’s
inability to perform a task successfully because of an insufficiency
in one or more areas of functional capability: physical function,
mental function, agility, dexterity, coordination, strength, endurance,
knowledge, skill, intellectual ability, or experience. Disability
is not necessarily related to any health impairment or medical condition,
although a medical condition or impairment may cause or contribute
to disability. Disability requires a conceptual definition. Disability,
which may be temporary or permanent, is the gap between what a person
can do and what the person needs or wants to do. It is defined by
the AMA Guides5 as
an alteration of an individual’s capacity to meet personal,
social, or occupational demands or statutory or regulatory requirements
because of an impairment. There are degrees of disability, usually
termed partial or complete. Many
factors affect these determinations because disability refers to the
fit between ability and function in a job. The definition of disability is
based on the physician’s determination of medical impairment,
the demands of the occupation, and the individual’s situation.
Factors such as age, regional job opportunities, intelligence quotient,
educational level, and biosocial issues are important with regard
to how the disability affects the individual’s life6. Disability is not usually determined
by a physician.
Impairment is the loss of a physiologic function or
of an anatomic structure. The AMA Guides5 define impairment as a deviation from
normal of a body part or organ system and its functioning. Impairment
assessment is deemed a medical evaluation, whereas disability is determined
in an operational setting such as the workplace or in a structured
evaluation of functional capacity based on observations of the individual’s
ability to carry out particular tasks or to perform specified functions.
An impaired person is not necessarily disabled.
The law is a term that lawyers often use to refer
to the controlling rules of the litigation. The law is made up of statutes,
regulations, and common law. Statutes and regulations are written
documents that explicitly define certain rules and duties, although
they are often subject to different interpretations. The common
law is simply prior judicial decisions (precedents) that impose obligations
and liability on certain persons. For example, if a shop owner does
not shovel the sidewalk and a person slips on it and falls, the
shop owner is liable for the damages to that person. Although certain
legal principles are uniform, the law varies from state to state and
between state courts and federal courts.
An expert is defined in most jurisdictions as any
person who by "knowledge, skill, experience, training,
or education" has "scientific, technical or other
specialized knowledge" that will aid a judge or jury in
determining the facts at issue in a lawsuit5.
The knowledge must be of a type not normally possessed by the public
or the expert must have some specialized expertise such that his or
her opinion will aid the judge or jury. Experts may be retained
simply to assist an attorney in preparing his or her case or they
may provide testimony at the hearing.
Discovery indicates the right of one party to "discover" the
relevant facts of a case and the evidence that the other party has
before the trial. Cases are not supposed to be tried by surprise. The
primary mechanisms for obtaining discovery are interrogatories (written
questions), requests for production of documents, depositions (a
lawyer questioning a witness in the presence of a court reporter
and the opposing lawyer), and subpoenas. It is important to note
that, if an expert is hired but his or her opinion is not going
to be used at the trial (for example, when the opinion does not
support the party’s position), the opinion is usually not
discoverable.
A party may pose written questions to the other party in litigation;
these questions are called interrogatories. The
interrogatories may relate to the facts of the case as well as to potential
evidence at the trial. An interrogatory requesting information about
an expert witness may ask the respondent to state the subject matter
on which the expert is expected to testify, to state the substance
of the facts and opinions to which the expert is expected to testify,
and to summarize the grounds for each opinion.
A deposition is an oral examination of a person outside
the courtroom and before the trial. A party may take the deposition
of any witnesses, including expert witnesses, to discover what they
will say at the trial. If witnesses are unavailable at the trial,
their deposition testimony may be offered into evidence. In addition,
if witnesses testify at a trial, their deposition can be used to
impeach them if they make statements that are inconsistent with
their prior deposition testimony. A deposition may be taken at any
location but it is usually held at an attorney’s office
or at the witness’s place of business. The attorneys for
both sides as well as a court reporter are present, and the court
reporter transcribes the attorney’s questions and the witness’s answers.
If an attorney objects to a question, he or she states the objection
so that the judge can rule on the objection later, when the judge reads
the deposition testimony. The witness must still answer the question,
unless the attorney who represents him or her gives instruction not
to answer the question, as when a privileged attorney-client matter is
involved.
A party may ask the other side to produce certain documents. Similarly,
a subpoena can be sent to non-parties to compel them
to produce documents, appear at a deposition or a trial, or give testimony.
Evidence is the testimony that has been heard and
the documents that have been admitted at a trial. The judge or jury
must base their decision only on the evidence admitted. In selecting
a physician’s written statements for admission into evidence, the
counsel and the physician must be certain that these statements properly
explain the client’s position.
Hearsay is a statement that is offered into evidence
by someone other than the person who made the statement; normally
it is not admissible.
Determination of causation, apportionment, and aggravation is
vital for the speedy resolution of the Workers’ Compensation
legal requirements. These three words can often delay or limit treatment, reduce
or eliminate financial restitution, and adversely influence the outcome
of care of work-injured patients. Causation is
defined as a physical, chemical, or biologic factor that contributed to
the occurrence of a medical condition5.
To decide that an alleged factor caused or contributed to the occurrence
or worsening of a medical condition, it is necessary to verify both
that the alleged factor could have caused or contributed to the occurrence
or worsening of the impairment, which is a medical determination,
and that the alleged factor did cause or contribute to the occurrence
or worsening of the impairment, which is a nonmedical determination. Apportionment is
an estimate of the degree to which each of various occupational and
nonoccupational factors may have caused or contributed to a particular
impairment. Aggravation means that a physical,
chemical, or biologic factor, which may or may not be work-related,
contributed to the worsening of a preexisting medical condition.
If the information is insufficient to accurately assign causation,
determine apportionment, or assess change resulting in aggravation,
then the physician needs to explain that decision.
Possibility and probability are terms that refer
to the likelihood or chance that an injury or illness was caused
by or aggravated by a particular factor. Sometimes possibility is
used to imply a likelihood of <50% while probability
is used to imply a likelihood of >50%.
Any factor included in a rating guide should be relevant to
the correlation of the results of an injury with functional loss. Amputation
of an index finger is a clear example of a highly relevant factor,
whereas imaging findings of degenerative changes in a spinal disc
or a glenohumeral joint may represent only age-related change. Such
imaging findings often may document premorbid alterations and may
have little relevance to the process causing symptoms leading to
functional loss. The concept of relevance is closely linked to that
of accuracy, which refers to the closeness of any measured
quantity to the true quantity. For example, a simple two-armed goniometer
may be highly accurate in defining elbow flexion-extension, whereas
the same device may be grossly inaccurate when applied to the compound
regional (lumbar and hip) mobility involved in flexion at the waist.
The recognition of compound motions involved in spinal movement
has led to substantial advances in the accuracy of techniques for
its determination, such as inclinometric motion measurements. A
lack of defined values for normal range of motion according to age,
dependence on the cooperation of the patient (client), and a lack
of documented relevance to impairment and disability are but a few
of the shortcomings of range-of-motion evaluations. For the spine, these
shortcomings have led to the system of diagnosis-related estimates
(DRE)7. Other physical examination
factors (such as strength and appearance) remain the hallmark of evaluation
of upper-extremity impairment because accuracy and relevance to
functional loss should be verifiable in the region. The future of
impairment evaluation is likely to emerge from improved methodology
for measuring functional loss through more relevant and accurate
systems of quantifying the results of physical examination.
Fairness is a concept that refers to the relationship
between the measured impairment rating and the actual alteration
of health status and physical function experienced by the patient.
This issue is usually of greater interest to the patient and the
examining physician than it is to the other parties involved in
the Workers’ Compensation claim. Fairness is closely related
to the ability of a numerical rating to quantify an actual degree
of functional loss. In the musculoskeletal system, this ability
is increased when there is simple visual access to a discrete anatomical
unit as well as a contralateral, normal side for comparison (such
as is the case with the hand). In contrast, absence of visual access
and contralaterality (such as is the case with the spine) creates
barriers to observing functional loss.
Communication takes place when a thought or idea expressed by
a sender is delivered to a receiver. For that thought or idea to
be properly interpreted by the receiver, the sender and the receiver
must have a common frame of reference and speak the same language.
With regard to disability evaluations, physicians and nonmedical
personnel must be able to communicate, using the same definitions,
about medical problems and limitations as they apply to the workplace.
Physicians are trained to assemble and analyze medical information
and to communicate with each other within a framework of established
medical diagnostic criteria and generally accepted medical principles
and practice. This highly technical and specialized medical language
must be translated for communication with nonmedical users of medical information.
The legal system has its own highly specialized language. Definitions
of the same word may be different for each party. Communication
is the successful flow of this information, in both directions,
in an understandable, supportable, reasonable, and useful format.
Physicians are the primary decision-makers in traditional health care,
but in the independent medical examination this role is yielded
to other participants. This can often lead to frustration or confusion
on the physician’s part, particularly when every word is
being challenged in an adversarial format common in court testimony.
Physicians must become more than casually acquainted with the
specific provisions and procedures of the employment and Workers’ Compensations
laws and regulations in the states where they practice, the Social
Security Act, the Americans with Disabilities Act, the Family and
Medical Leave Act, and the regulations published by the federal agencies
administering these statutes. Recognizing the need for appropriate
references, the Occupational Health Committee of the American Academy
of Orthopaedic Surgeons has been developing state-specific information
that can be found on its home page (www.aaos.org) with a search
for "Health Policy and Related Issues" or a general
search for "Workers’ Compensation." In
addition, the Academy offers a yearly continuing-education course
on Workers’ Compensation.
Throughout history, disability and impairment have been unwanted human
conditions. However, it is only in modern times that they have been
accorded legal status. As I stated previously, the definitions of disability
expand and contract more along political and ideological lines than
according to any clear physical determinations. This has resulted
in a mismatch between impairment and disability, since impairment
is associated with disability only insofar as it is a necessary
and contributory factor; in itself, it is not sufficient to cause
disability. The concept that an individual who is impaired is not,
as a consequence, necessarily disabled was clearly developed in
the AMA Guides5.
However, the United States Social Security System rests on the premise that
disabled persons would be employed or have opportunities for better
employment if not for their illness or impairment. Unfortunately,
this premise is flawed, as accumulated social policy and medical
research have shown; the current medical impairment model has proved
insufficient for understanding and dealing with disability. Currently,
the scope of individual disability is broader than the administrative
legal concept; judicial interpretation tends to rebalance the scale
in favor of individual needs and rights when issues of entitlement
are disputed. Modest, even minor, impairments that arguably are
disabling can become important when more immediate socioeconomic
and demographic factors contribute to an individual’s difficulties8.
Thus, disability and evaluations to determine disability are
unstable concepts constantly beset by structural tensions within
any social disability system. Pressure for expansion is exerted
not only by individuals with perceived needs but also by all who
profit from the system. It is possible for physicians and other
providers who are supposed to be the official gatekeepers of the
impairment boundary to expand the duration and definition of disability
with questionable tests and treatments for which they receive payment.
Attorneys who are better served by the popular conception of disability
than by the stricter administrative legal concept have little professional
interest in securing a firm boundary for disability. On the other
side are legislators, insurers, and employers who may be trying
to limit the appropriate definition of disability.
The interface between physicians and the legal world is not always
an easy one. Confusion between the professions requires that care
be taken whenever the law and medicine interface. Both are complex fields,
with many important decisions being made, and neither field is an
exact science. However, if the physician has a minimum level of understanding
of the legal system and the lawyer has an adequate understanding
of the medical facts and the limits of medical science, the medical-legal
interface can be a successful one. Some physicians are too fearful
of interacting with the legal world, and some are not cautious enough.
Physicians who see a potential lawsuit at every corner and thus
refuse to give a written opinion or hesitate to use terms and statements
like "symptom magnifier," "symptoms are
disproportional to the findings of the clinical examination," "the
clinical examination does not support this level of subjective complaints," or "the subjective
complaints do not follow an anatomical pattern" may be
too cautious. These statements are accurate objective descriptions
that reflect the observations of the physician who performed the
independent medical examination, and they are less likely to invite
confrontation since the physician is not stating that the individual
is a faker or is being dishonest. Physicians who assume that they
can do whatever they want, relying either on bluffing or on their
malpractice insurance, are also mistaken. Lack of caution and overcautiousness
usually come from a lack of knowledge of the legal world. Thus,
although it never can be guaranteed that a physician will not be
sued because of his or her opinion, a physician who is too cautious
to ever give a definitive opinion is useless to the legal system.
The key for the physician is to understand the legal issues while focusing
on the medical questions. It is important to recognize that when
physicians testify in court, they are usually offering a medical opinion
as an expert witness. The courts have grappled with minimum standards
for an expert witness’s opinions, so that "junk
science" can be excluded from the courtroom. Thus, physicians
must have a minimum scientific basis for their opinions before they
are allowed to testify in court.
A consistent and acceptable definition of disability is needed
before its costs can be estimated. Estimating the costs of disability
requires establishing both the number of disabled people and the
average cost of disability. One source for the number of disabled
people is the National Health Interview Survey, which consists of
a representative sample of the population and has been completed
for three decades9,10. Individuals
are asked whether they have an impairment or health problem that
prevents or limits their activities and whether that condition is
chronic (lasting three months or more). Respondents are classified
according to the degree of activity limitation. The least severe limitations
are those that do not affect the person’s major activity. The
most severe limitations are those that prevent the person from carrying
out his or her major activity. The major activity is defined according
to the person’s age: for children, it is attending school;
for individuals between the ages of eighteen and sixty-nine years,
it is working outside the home or homemaking; and for individuals
seventy years of age and older, it is living independently. Each
of these concepts (chronic condition, limitation, major activity,
and age cutoffs) can be subject to second-guessing. Since the information
is self-reported, additional bias can occur. The National Health
Interview Survey data for 19919,10 suggest
that more than thirty-three million persons have limitations, with
almost ten million of them unable to carry out their major activity
and an additional 2.2 million residing in institutional facilities.
Disability rates are higher for male, black, low-income, and older individuals.
Two approaches have been used to estimate the cost of disability.
The prevalence method relies on cumulating the costs incurred by
all persons with a condition in a given year. The incidence method
derives the present value of lifetime costs by summing the present
cost and the discounted value of all future costs. Typically, economists
measure costs by asking how much output or product is expended or
is foregone as a result of the disability. Examples of foregone
output are partial or total loss of the disabled worker’s
earnings and loss of earnings from family and household members
as a result of their inability to earn because of the time devoted
to caring for the disabled person. Major expended outputs are the
medical, hospital, pharmaceutical, attendant, equipment, and refurbishing expenses
needed to care for the impaired or ill individual. It should be
apparent that efforts to carry out these calculations involve a
variety of assumptions that will affect the final estimation of
costs. With use of the prevalence approach, the aggregate costs
of disability in 1980 were calculated to be $177 billion,
or about 6.5% of the gross domestic product for that year1. Health care represented 51% of the
cost; lost earnings, 39%; and administrative costs, 10%.
Hill11 reported the direct costs
of disability in 1984 to be $145 billion using a different
set of assumptions and limiting the disability group to persons
between the ages of eighteen and sixty-four years. These estimates
do not include the costs of pain and suffering, which are real costs
that the courts and juries are frequently called upon to consider. Because
pain and suffering are so difficult to evaluate and because there
are economic incentives to embellish or diminish their scope, it is
understandable that substantial suspicion surrounds claims for damages.
Indirect costs of disability can be measured by transfer payments, which
are payments from one agent to another that are not for products or
services rendered. Examples include private and social insurance
benefits and government payments to those with perceived economic
needs. Welfare recipients may have needs due to disability but welfare
benefits are not included in the economic costs of disability. One
household receives money (welfare benefits) to spend, resulting
in someone else (for example, a taxpayer) having less available
for that purpose. Since one person’s gain is balanced against
someone else’s loss, no real resources are lost to society.
A study by the Bureau of Economic Research (Rutgers University)1 estimated that cash transfers to
the disabled in fiscal year 1986 exceeded $97 billion,
with the leading sources of these cash transfers being Social Security
Disability Insurance (SSDI) ($22.5 billion), privately
obtained disability insurance ($11 billion), Workers’ Compensation
indemnity benefits ($12.4 billion), compensation for bodily injuries
sustained in automobile accidents ($9.3 billion), compensation
for disabled veterans ($5.7 billion), and welfare (covered
under Medicaid and Medicare) ($36.1 billion). During hearings
on the Americans with Disabilities Act, the Commissioner of the
United States Equal Employment Opportunity Commission (EEOC) testified
that "one dollar in every 12 that the Federal Government
spent was a direct payment to a disabled person or to a disability
program."1
Who is footing the bill for disability? Surprisingly little research
has been done to address this question. Workers’ Compensation
and Social Security Disability Insurance are economic mainstays
of disabled workers and their families. These programs were designed
to help replace the lost earnings of covered workers who meet certain
eligibility criteria. Yet neither program seeks to replace the full
earnings lost as a result of disability; consequently, the disabled
individual inevitably shoulders some of the financial burden of
the disability. Most Workers’ Compensation programs aim
to replace two-thirds of lost gross earnings. Commonly, the Workers’ Compensation
benefits are not taxed. This can result in a substantial increase
in the total take-home amount, which on occasion is equal to the
usual after-tax paycheck. All programs have initial waiting periods
during which the individual is not compensated, and all have statutory
caps on weekly compensation benefits. Many individuals also have
private disability insurance, either provided by their employer
or personally purchased. When this payment is added to the nontaxed Workers’ Compensation
benefits, the total amount may be more than that earned when the
individual was working. Disability benefits are very rarely provided
for a person’s lifetime, and only a few states provide any
cost-of-living adjustments of long-term benefits. Not infrequently, workers
must also pay the costs of litigating for the benefits that they receive.
It seems clear that sometimes there can be a sizable gap between
losses incurred by an individual who becomes disabled from a work-related
injury and the transfer payments typically provided. The gap is
especially large when persons lose time from work or, especially,
when they lose their jobs because of the disability.
Everyone loses when patients are disabled for long periods. The insurer,
employer, and society suffer the economic losses while the employee
suffers the personal losses. The opportunity to change the current
lose-lose situation to a win-win one lies in prompt treatment and
early return to work. The interests of the injured worker, the financial
interests of the employer and the insurer, and the intended fairness
of the system would be served best by a joint effort by all parties
to reduce the period of disability and to promote the return to work.
Physicians must be the patient’s advocate and be willing
to suggest that an injured worker (client) seek legal advice in
select situations when the employer is not dealing with him or her
in an appropriate manner. On a system-wide level, they must help
end the possible antagonism between employers and employees. The treating
physician can improve the quality of life of the injured worker by
using the science of medicine to treat the anatomical injury, thereby decreasing
the physical impairment. He or she can also use the art of medicine
to address the biosocial issues, thereby decreasing the disability
from the injury; this will result in less handicap and improved
treatment outcomes for the individual at a lower financial cost.
This approach provides treating physicians with a unique opportunity
and obligation to provide reasonable workplace guidelines in an effort
to reduce work disability, improve the outcome after work-related
injuries, and enhance the quality of life of their patients. Returning
the individual to work requires a balance between the demands of
the job and the capability of the patient. Many studies have demonstrated
the advantages of early return to work by injured workers12-29. Examples of these benefits include improvements
in self-image30, the ability to
cope31, work survivability12, and self-sufficiency; therefore,
they are in the best interest of the patient (employee)19,20,23,32,33. Conversely, prolonged
time away from work makes recovery and return to work progressively
less likely34.
Physicians often find return-to-work and workplace guidelines
frustrating and time-consuming. Since return-to-work guidelines
are not an exact science, the process can often be confrontational
and nonproductive instead of cooperative and productive. Commonly,
there is little or no formal training regarding return-to-work issues
during residency training. Occasionally, the patient wants to negotiate
the workplace guidelines or simply refuses to go back to work, often resulting
in a difficult situation. It is important for the physician to provide
guidance. Workplace guidelines are simply guidelines; they are not
written in stone. They should be flexible and be adjusted for the
individual patient’s response to treatment. An understanding
of the symptoms, signs, job description, essential functions of
the job, accommodation options, employer willingness, employee willingness, previous
workplace guidelines (from the family physician, company physician,
or another source), response to previous modifications of work activities,
and current work status are required to provide reasonable workplace
guidelines. When information regarding job performance in the workplace
is not available to assist the physician in determining appropriate
guidelines, a Functional Capacity Evaluation (FCE) may be of help.
Validity testing is the key component of an FCE. As healing continues,
both job demands and the ability to meet those demands tend to increase. This
allows for a natural transition from work requiring accommodations
to regular work. Return-to-work reports should be understandable
in lay terms with restrictions expressed in terms of functional impairment
(for example, lifting and motion limits) rather than job category
(for example, carpenter or truck driver), unless the physician is sure
of the exact physical requirements of the job.
The importance of preventing disability-related and medically
unnecessary time off from work can be placed in perspective by considering
all of the people who, although substantially limited in their ability to
carry out life activities, insisted so strongly on their right to
work that Congress passed the Americans with Disabilities Act35.
Treating physicians are advocates for their patients. However,
when physicians agree to provide an independent medical examination,
their role changes to one of impartial scientist. The physician
must review the information, match the history to the injury, complete
an examination, look for links between subjective complaints and
objective findings, analyze relationships, develop conclusions,
and provide a written report that supports these conclusions on
the basis of the medical evidence in a format that is understandable
to all. This task can be daunting, time-consuming, and unrewarding.
Commonly, the individual receiving the independent medical examination
has preconceptions about the physician that can affect the history-taking
and the physical examination. Occasionally, these preconceptions
have led injured workers to commit hostile acts against and even
to inflict physical injuries on physicians performing independent
medical examinations. Secondary gains and biosocial issues can intentionally
or unintentionally affect the examination. Because of these complexities and
the change in roles, many physicians elect not to perform such examinations.
However, with appropriate training, attention to details, and a
desire to be an honest reporter of the facts, those who do perform
independent medical examinations can provide a valuable and necessary
service to society.
Demeter SL, Andersson GBJ, Smith GM.Disability
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