28 February at 08:24 from atlas

    • BRIEFING for IMEs in medico-legal matters.

         Share26 February at 18:35 from atlas

       Let us talk about briefing of an IME! 

      Briefers  at times ,send us limited  objective material ('evidence') yet expect answers to pages of questions to the level of absolute certainty able to withstand robust cross examination in a court of law and by our colleagues who are very discerning, and at times most critical!

      They may need to consider the equivalent  sequential logic of a police prosecution brief. This commences with the description of the  alleged event, various  contemporaneous witness reports, statement of accused, scientific/forensic reports and the relevant legislation.

       As an IME one  may see a treating surgeon's report some months after the DOI being told of 'sciatica' , no imaging films, no incident report, no employer report and no contemporaneous GP records. All of the material especially the  contemporaneous clinical notes are CRUCIAL. 

      By the time the claimant(patient) is seen by the  treating specialist there may rarely ,and  at times rarely inexplicably been a change in symptoms ,and rarely signs and these may  at times correlate with MRI changes.This change may be due : (I) the natural occurrence of spontaneous sciatica etc, (ii) damage caused by an intervention such as manipulation or injection of the spine, (iii) a further injury, and (v) other undetermined mechanisms.

      We know that MR changes are common in ASYMPTOMATIC adults ,both lumbar and cervical (see articles posted earlier),and these start age 20 !. See Brinjikji W et al, Table 2 (2015), AMA 5 pages 378 and 383, WC NSW and GEPI QLD PI Guidelines , Maureen Jensen /Michael Modic et al ,NEJM, 14 July 1994,etc. 

      We  ALSO need to SEE the actual films because we know that there is an large variability in reporting  nomenclature by some radiologists .The accepted North American & Canadian Combined Task Forces Guidelines on Lumbar Disc Change Nomenclature( Fardon D et al, 2014, Spine, Version2) adopted by the RANZ Radiologists at 2015 ASM may not be used by the reporting radiologist.They don't say in the report.  
      An IME doing their best to follow UCPR, American Board of Independent Medical Examiners (ABIME) and AHPRA/AMA Guides on good medico-legal practice, and trying to give logical and evidence based sequential evidence analysis  and clinical rationale based opinion and replies to pages of very blunt questions ( BTW of great importance to the Claimant and the Briefer) may get tired of repeating all this after over 3 decades. The IME NEEDS full and comprehensive contemporaneous and sequential briefing and not a few certificates and a surgeon's report a year after the incident with no incident report or contemporaneous clinical findings notes.We sadly receive such briefings and are expected to answer pages of questions without prevarication and if we don't there follows a 'supp request' !

      A good briefer will get the BEST report if they supply AT THE minimum: (i) Incident Report, (ii) Employee report, (iii) Employer Report, (iv) Incident Investigation report by WHS or Police, (v) Ambulance Report, (vi) Hospital ED and Inpatient records, (vii) Contemporaneous treating GP notes for at least 3 months before and 3 months after the incident,(viii) job description,(ix) all Radiology FILMS, (x) all Radiology REPORTS, (xi) all operation reports,(xii) Surveillance descriptions and photographs of any covert surveillance. (xiii) all GP referral letters to Specialists, (xiv) all Specialists' clinical notes ,(xv) other IME or specialists' reports (xvi) the legislation, AMA Guide Edition and non-repetitive questions that are WITHIN the chosen IME specialist's field of expertise. 

      Without  providing ALL of this then the Briefer should carefully consider their expectations. Would a jurist  in a police matter accept no witness statements (viz contemporaneous GP clinical notes) in assessing a case 3 years after the event? NO. Neither should an IMEA lot turns on jurist's ,and an  IME's report to both parties. The situation is often adversarial and the IME report may not please BOTH Briefer and Claimant. Further there may be different medical/surgical opinions on many matters. Mediciine is an Art and a Science.However , if a finding is made it should be to a reasonable degree of medical certainty and be sustainable on accepted medical/surgical body of knowledge. In the absence of briefing which forms the substrate to an opinion the IME may struggle to defend their opinion in the event of an official  complaint or robust cross examination in court. The IME should always explain the clinical rationale used in coming to conclusions and GOOD BRIEFING is CRUCIAL here. A robust  IME report/assessment  relies on solid substratum of objective  referenced clinical evidence and well reasoned and thoroughly documented clinical reasoning and rationale in keeping with published and accepted medical, surgical and radiological standards of practice.With poor briefing this is often not possible. The Briefer knows/should know this-the IME should be aware of this in making findings without ALL relevant material and any findings made that he/she feels uneasy with, for whatever reason, should contain a declaration of incomplete briefing and limited conclusion, or no conclusion, being made. The IME can be subject to AHPRA and civil action as he/she is practising Medicine even though they are NOT providing treatment. The Briefer may not support or assist the IME in that event. Good medico legal practice requires making findings to 'a reasonable degree of medical certainty' based on available(provided) information along with clinical evaluation on the day of assessment. An IME being encouraged, and at times 'directed' to 'make findings' ,WITHOUT all of this crucial information. He /she  would be well advised to decline  answering any questions that are not reasonably able to be answered ( to a reasonable degree of medical certainty)with available briefing along with history and examinations performed,and explain WHY. With unsatisfactory briefing the Briefer should expect that some questions are unable to be answered'-guessing' is NOT good enough, even if 'educated'.  The IME should advise material deficient in his or her opinion as part of content validation.It is equally important to star what was viewed and considered as well as what was NOT viewed that may have been equally important. IMEs may be criticised for reaching conclusions without all information and hence they must document deficiencies in the interests of completeness so there can be no misunderstanding whatsoever.
    • The requirements and methodology of causation and apportionment analysis are well published and described in texts  of the ABIME/AMA and text 'Analysis of Disease and Injury Causation', Ed 2, J Mark Melhorn et al',published by the American Medical Association. Pages 100 onwards deals with content requirement.
       Briefers have access to highly experienced and capable specialists to work with-  THUS one trusts that the Briefer and IME specialists consider these issues.Adverse results-both administrative and surgical may result with poor advices. In this instance the problem remains the property of the Briefer, IME, Claimant/patient and  treating/operating surgeon/physician involved.
    • The BEST information is often found in the INITIAL contemporaneous medical records YET they are often NOT provided to the IME. The reason for this deficiency is unclear. 
    • Radiology films are often not provided.The IME must be aware of the potential for mistakes to occur in accepting reports without personally viewing films. There is ample literature indicating the variation in lumbar spine MR reporting by a number of different observers- 'inter-observer variability')."Bulges' 'protrusions', prolapsed' herniations', 'annular fissures' , 'annular tears' ares terms which are often used interchangeably. None should imply causation. The North American and Canadian Combined Task forces group has published Version 2 guidelines on lumbar disc change nomenclature(DF Fardon et al 2014 Spine) and these have been adopted by the RANZC of Radiologists at the 2015 ASM.
    • Only the best and most accurate  information should be considered in formulating an evidence-based IME assessment and content /methodology must be documented as this is a scientific and medico legal document.
      The opinions stated herein are entirely those of the author. References both textbook and scientific citations are available. 
      Please refer to ABIME, AHPRA, AMA(Aus) , AMA (USA),State/Federal mandated and UCPR Guidelines on good  and appropriate medico-legal practices. 
      Dr Michael Coroneos.
    • Master CIME & Senior Neurosurgeon.

      Briefers,Medico legal advisors and IMEs should seek specific advice and directions. This article is a  general and non-specific discussion article and does NOT constitute advice.The opinions are those of the author.


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