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Erroneous Ratings Study: Part III
In the prior issue we discussed our national
study of 2100 impairment rating reviews and presented our
findings: 80% of all ratings reviewed were erroneous, with 89%
of the erroneous ratings being elevated. In this issue we will
start to explore some of the causes of erroneous
ratings.
There are many cases of erroneous ratings,
including bias, differences in clinical and causation
assessment, and misapplication of Guides criteria, either
through lack of knowledge and skills in rating impairment or
intent. The nature of the errors is such that most erroneous
ratings will be higher, rather than lower. Most medical
schools and residency training programs do not include
instruction on the assessment of impairment, disability, or
causation. Therefore many physicians lack an adequate ability
to assess these and other medicolegal issues.
The principles of assessing impairment are
provided in Chapters 1 and 2, however it appears that often
physicians have not become familiar with the rules presented
in these chapters, and rather focus their attention on
chapters specific to the region they are rating. Chapter 2,
Practical Application of the Guides, is a particularly
important chapter, not only for rating physicians, but also
for attorneys. This chapter specifies rules and standards for
the impairment evaluation. It also provides superb content for
an effective cross-examination of a physician who has
performed an erroneous rating. Section 2.1 defines impairment
evaluations, Section 2.2 discusses who performs impairment
evaluations, Section 2.3 identifies the roles and
responsibilities of the examiner, Section 2.4 explains when
ratings are performed, Section 2.5 provides critical rules for
the evaluation, and Section 2.6 outlines standards for
reports. Failure to follow the defined procedures will result
in an erroneous report. Section 2.6 Preparing Reports provides
detailed standards for reports. Failure to follow these
standards will result in a questionable report and
rating.
The rating physician must be “independent and
unbiased”. This can be challenging for any evaluator, however
it is more likely to be problematic for the treating physician
since there is an inherent patient advocacy role. (Barth RJ,
Brigham CR, Who is in the better position to evaluate, the
treating physician or an independent examiner?, Guides
Newsletter, November – December 2005). The Guides state on
page 18 “An impairment evaluation is a medical evaluation
performed by a physician, using a standard method as outlined
in the Guides to determine permanent impairment associated
with a medical condition. . . .The physician’s role in
performing an impairment evaluation is to provide an
independent, unbiased assessment of the individual’s medical
condition, including its effect on function, and identify
abilities and limitations to performing activities of daily
living as listed in Table 1-2.”
A skilled independent medical evaluator
typically spends more time with a patient than a treating
physician at a single visit, and therefore may obtain clinical
information not known to the treating physician. It is
probable that the treating physician will not consider
alternative or new diagnoses at the time of rating. It is
possible that the treating physician will causally relate
problems to an injury if this appears advantageous to the
patient and/or the physician. For example, if a treating
physician receives referrals from plaintiff counsel it is not
unexpected that this physician will causally relate problems
to the defined injury and may inflate a rating. A treating
physician caring for a patient in a managed care situation may
be more likely relate a problem to an injury if this provides
an additional source of revenue. The treatment role may
influence when the physician defines maximal medical
improvement (MMI), i.e. at discharge from care the physician
may be inclined to define the patient as ratable, even though
it is probable that the patient is not yet at MMI. A treating
physician may want to increase a rating, particularly if the
impairment number does not appear to reflect a level of
perceived disability.
In the next issue of the ezine we will examine
some of the common errors in clinical assessment that lead to
erroneous ratings. If you do not yet subscribe to the ezine,
visit www.impairment.
c om to subscribe – it is valuable and provided as a
public service.
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Greetings!
Due to the results of our poll last month, our next seminar
on advanced Guides issues will be August 4, 2006 in San
Francisco! We'd like to thank all of those who gave feedback
using the poll. Details below...
Informative articles regarding Erroneous Ratings Study as
well as Tools of the Trade are included in this issue. Please
let me know if you have any topics for article requests. We
want to bring you information to further your success!
Check out the "Calendar of Events" below to see what we
have going on for conferences this year.
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New AMA
Guides Skills Assessment &
Mini-Assessment |
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Chris Brigham, MD has developed an in-depth Skills
Assessment on the AMA Guides that is essential to
those who perform, review or manage impairment ratings. This
is a dynamic on-line assessment involving 60 questions which
will take approximately 2-3 hours of time.
- Group Discounts for 25 or more examinees
- $195.00/exam
Mini-Assessment also available! This assessment is
an exceptional screening tool for organizations with
adjusters, attorneys and physicians who would like to have a
gauge on their proficiency in the Guides. This
assessment tool involving 20 items will take approximately 1
hour of time.
- Group Discount for 25 or more examinees
- $75.00/exam
- Register On-Line or Call 619-299- 7377
Each question is based on a random selection of questions
from specific areas of the Guides. Therefore, each examination
is different.
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Details & Registration
Here |
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AMA Guides
Webinar 102: Case Exercises - April Session |
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AMA Guides Webinar 102 - Case Exercises builds on basic
knowledge to master the use of the Guides. This seminar
is based on a series of case exercises that illustrate the
impairment evaluation process. In advance participants can
independently assess cases. During the seminar Leslie Dilbeck,
CIR, will go through the rating process step-by-step,
including the steps involved.
- Schedule: (All sessions held from 2-4pm P.S.T.)
- Thurs. April 6, 2006, Chapter 17: Upper Extremity
- Thurs. April 13, 2006, Chapter 16: Lower Extremity
- Thurs. April 20, 2006, Chapter 15: Spine
- Thurs. April 27, 2006, Chapters 3-13: Other Areas
Price: $395.00/4 Sessions |
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Click Here to
Register! |
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ACOEM
Pre-Conference- Los Angeles, May 5-6 by Brigham
Walker |
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Chris Brigham, MD & Phil Walker, JD will be teaching
the pre-conference, two day course on May 5 & 6: "Master
the AMA Guides" as part of the American Occupational
Health Conference (AOHC May 5-10, 2006). This seminar is
case-oriented and designed for physicians and others who want
to improve their ability to rate impairments. They have
received superb reviews: informative, lively, and not to be
missed!
- Start Date: Friday, May 05, 2006
- End Date: Saturday, May 6, 2006
- Event Time: 8:00am - 5:00pm
- Location: Hyatt Regency Century Plaza Hotel: Los
Angeles, CA
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Register Here! |
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Upcoming
Seminar- AMA Guides: The Next Step: Advanced Skills &
Practical Application |
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This advanced seminar will provide attendees with the
knowledge to assess impairment in complex areas such as
multiple upper & lower extremity injuries and
corticospinal tract injuries. There will also be discussion on
common areas of misuse and abuse of the Guides along
with current trends seen with erroneous ratings.
Physicians, attorneys and claims staff are encouraged to
attend.
- Date: August 4, 2006
- Where: San Francisco Airport Marriott
- Time: 7:30am- 4:30pm
- Price: $395.00/attendee (Group discounts available)
- Register On-Line or Call 619-299-7377
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Register Here! |
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Calendar Of
Events |
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Dr. Brigham will be a featured speaker at the following
events:
California Workers’ Comp Forum, San Bernardino, CA, March
14, 2006
California Applicant’s Attorney Association with Steven
Feinberg, MD, Wailea, Maui, April 3-4, 2006
California Orthopaedic Association with Phil Walker, San
Diego, CA, April 21-23, 2006
American Occupational Health Conference, Los Angeles, CA,
May 5-6, 2006
California Joint Powers Authority, September 20-22, 2006
We will be exhibiting at the following events:
- Division of Workers' Comp Educational Conference, Los
Angeles, CA, March 1-2
- California Self-Insurers Association, Downey, CA, March
27, 2006
- Risk & Insurance Management Society 2006 Honolulu
Conference, Honolulu, HI, April 23-27
- California Workers Compensation Defense Attorneys
Association, Lake Tahoe, CA, May 18-21, 2006
- National Workers' Comp & Disability Conference, Las
Vegas, NV, Nov. 13-15, 2006
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Tools of the
Trade: Two Point Discriminator |
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This is the fourth article of a series which is taking a
closer look at credibility in physical examinations. By now
you have likely had the chance to consider how clear the
Guides are in their directives regarding how physical
examinations should be performed and how the data should be
collected. As has been previously acknowledged, Chapter 2 of
the Guides provides the “rules” physicians must follow for
doing evaluations. Each chapter in the Guides also provides
specific instruction on how the evaluation for that region
should be done. We have looked at the use of inclinometers for
spine evaluations, goniometers for joint range of motion and
Semmes- Weinstein monofilaments for light touch sensations
(ie. neurological examination).
This article will focus on the use of the two-point
discriminator which is also used for measuring sensory
deficits. The two most common injuries for which this type of
testing is done involves carpal tunnel syndrome and digital
nerve lesions. For any peripheral nerve condition such as
carpal tunnel syndrome, diminished two-point discrimination
assists the evaluator in grading the severity of sensory
deficit but does not give specific parameters such as is with
the case of digital nerve lesions. Digital nerve lesions are
handled a bit differently in that the Guides provide specific
criteria for defining the quality of two-point discrimination.
Based on the criteria provided by the Guides the evaluator is
able to determine if there is total, partial or no sensory
quality impairment.
Two-point discrimination is measured by using the Two-Point
discriminator. Two-point discrimination is discussed in
Section 16.3 Sensory Impairment Due to Digital Nerve Lesions
(5th ed., 445-446-450) and is used for the evaluation of
“sensibility losses in the digits associated with lesions of
digital nerves” (5th ed., 445). There are very explicit
directions on the process. “Two-point discrimination has its
widest application for individuals who have sustained nerve
lacerations” (5th ed., 446).
The Guides explain the process: “The classic Weber static
two-point discrimination test is most valuable. Moberg
originally described the use of a paper clip opened and bent
into a caliper. The Disk-Criminator, DeMayo 2-Point
Discrimination Device, and Boley Gauge are some of the
currently available testing instruments. Testing is started
distally and proceeds proximally. The distance between the
tips of the instrument is set first at 5 mm. As the individual
being tested closes his or her eyes, the tips of the testing
device are applied lightly to the sides of the pulp of the
distal segment of the digit in a random sequence, in a
longitudinal orientation. Because it is light-touch
discrimination that is being tested, the pressure applied
should be very light and must not produce a point of blanching
or skin indentation. The interval between applications should
be no less than 3 to 5 seconds. A series of touches with one
or two points is made, and the individual immediately
indicates whether one or two points are felt. Two out of three
responses must be accurate for scoring. The distance between
the ends is progressively increased until the required
accurate responses are elicited, at which time the distance is
recorded.” Unfortunately, it appears few physicians adhere to
these standards.
The Guides note “Sensibility assessment is one of the most
challenging tasks in impairment evaluation. The subjective
nature of sensibility testing can relate to a number of
variables involving the testing environment, the individual
being tested, the test instruments and methods of
administration, and the examiner. Tests should be administered
in a quiet environment void of extraneous noises that distract
the individual and the tester. Examinee-related variables can
include attitude, concentration, anxiety, and the like.
Abnormal skin texture, such as calluses, also influences the
test results. Instrument-related variables include
manufacturing quality control, readjustment of calibration as
needed over time, and the weight of various instruments.
Important method-related variables include rate and duration
of stimulus application, the amount of pressure exerted on the
skin, and whether the stimulus is moving or constant.
Instruments designed to control the force and velocity of
two-point or monofilament application and of other stimuli are
not yet available. The examiner's experience, attention to
detail, and adherence to methods of administration can
minimize the effects of the above variables.” Therefore, it is
essential to determine if the findings are reliable. If the
findings are not reliable, the rating will be erroneous.
The goal of our “Tools of the Trade” series is to provide
insight on the directives given in the Guides on data
collection. Accurate assessment of loss of function is
dependent upon the evaluator’s methodology in data collection
and application to the criteria set forth in the Guides. Our
next article will focus on the Jamar Dynamometer.
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