Independent Medical Assessments - Good , Bad or just Ugly?

[ghost dog]

Having done more than a few IMEs, I'm struck by the disimiliarity between the way in which orthopedic surgeons perform these and chronic pain physicians do .

Is it just me, or does Ortho always state the patient is medically fit to return to the workforce? This would be "the bad" part of IMEs.

If you can't drill something through their spine, "nothing is wrong"?

There will usually be co-morbid chronic depression and anxiety in the chronic pain population, but Ortho rarely (if ever) addresses the mental health aspect during an IME.

Has anyone else encountered this phenomenon? It is very irritating, and extremely difficult to refute the statement "nothing is wrong with this patient" to an insurance company once it has been submitted to their claims branch.

Of course, chronic pain patients do much better overall IF they are able to work , as their depression and anxiety seems to decrease with working.

However, it takes a tremendous amount of work to get them to this point where they are able accomplish the complex task of returning to the workforce. The usual Ortho recommendation of conservative treatment (i.e. "physio") has already failed, and thus it is up to us as chronic pain physicians to rehabilitate them. It is very rewarding , if rare, to return a patient to the workplace. This would be "the good" part of chronic pain work. Ortho makes it sound as if it is simple as catching a bus.

On the other hand, there will always be the patient who simply does not WANT to work. This makes the chronic pain patient's life (who is genuinely unable to work) extremely difficult and miserable. Differentiating between the patient who doesn't want to work and can not work is extremely difficult sometimes, and this makes an IME ethically and clinically challenging to say the least. This would constitute "the ugly" part of IME work.


GD.

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[Tenesma]

talking about IMEs -

patient w/ complete semitendinosus avulsion - saw two IMEs (both orthopedists - both chosen by her work. comp carrier)... they told her it was a strain, and that she could return to work - she tried to work but couldn't because she could barely walk... in one of the notes, one guy actually mentions a significant muscular gap, and weakness with knee flexion, and then in summary told her that there was nothing medically wrong and to return to work.

i saw her, her repeat MRI shows significant atrophy of the hamstrings, significant fore-shortening of the avulsed mucle - i get her in with a good orthopedist, who then states that this injury should have been repaired within the first month of injury (work. comp didn't allow an MRI until she did 2 rounds of PT of 6 weeks each - which she described as hell on earth - with the PTs refusing to treat her because they were convinced after a few sessions that she had a tear).... because of the extent of atrophy,foreshortening there is no longer a surigcal fix for this.

this woman now drags her leg, has constant pain at the avulsion site with weightbearing and is now being told she needs a 3rd IME because work. comp states the first 2 IMEs contra-dict my orthopedists views...

so, yes, i second your thoughts... by the time they get to me for an evaluation they typically have seen 2-5 doctors with the majority of them telling the patient that the patient is full of crap... 85% of the time I agree w/ the original findings...

 

[Mister Mxyzptlk]

There's an orthopedist my area who ALWAYS concludes that there is nothing wrong with the patient, it was just a simple strain/sprain, and if you and the other doctors had left the patient alone they would have been back to work in 6 weeks.

He usually goes into a vicious discussion of what idiots you and your colleagues are and rips apart whatever you did.

He couches everything in "this is just my opinion" so you can't sue him for libel. I once saw an IME on someone else's patient where he was citing articles from popular magazines with names like "Runner's World". He ripped the guy apart for diagnosing a cervical radic and seemed to be unaware of an MRI showing an HNP exactly where you'd expect it.

He is an instructor for the course on how to do impairment ratings. His lecture is sickening, as he goes into how smart and clever he is and how to write reports that won't get you sued.

If this guy ever needs orthopedic, PM&R, neurology or pain management I hope he gets a good dose of his own treatment. I wouldn't piss on him if he was on fire.

 

[Disciple]

Some states have instituted IME panels, where the injured worker is assigned for evaluation randomly.

This has decreased some of the "hired gun" type of med-legal work that goes on.

In my state, prior to institution of this measure, there were senior practicioners making fortunes in the med legal arena.

One in particular edits for ACOEM.

 

[ghost dog]

I'm glad to see I'm not alone in this issue.

On a related topic, what determinants or criteria do you use to differentiate between patients who don't WANT to work and patients who are medically unable to work?

I find that people who are self-employed to be a useful criteria , as they have no secondary financial gain issues at play. Their spouse sometimes has coverage for medication and physio, etc (this makes it easier to use meds). Canadian healthcare has universal coverage , and thus they don't pay me directly for interventional treatment.

Another helpful discriminator is patient refusal to pursue non-opioid related treatment (i.e. interventional treatment, etc). However, this is more related to aberrant opioid behavior, as opposed to the patient population that simply doesn't want to work. I imagine these two populations are closely related, though.

 

[Tenesma]

i hate to say this: but I have no clue about the difference between a patient that doesn't want to work and a patient that can't work....

clearly, if you see a patient doing cartwheels doing the beach, and that same patient is a cripple in your office - then you know they don't want to work...

One guaranteed technique to get an annoying patient out of your practice is to tell them to return to work and that you are going to document that there is NO medical reason they cannot work....

the pain psychologists actually have some sophisticated questionnaires that go into the "perception of disability" with some nebulous questions - and they can gauge fairly well whether somebody has ANY real intention of returning to work... whether it is accurate or not is completely up in the air... but so far, i have found their assessments to be very accurate --- in fact, they have predicted poor outcomes for my procedures in work comp patients like Nostradamus... then again, my work comp patients never get better anyway...

i have one Medicaid patient in her 40s (on medicaid because of depression) - she has settled one work. comp case already (she slipped on a wet floor), in the process of settling another work. comp case (door hit her back), and i am seeing her for her 3rd work. comp injury - diffuse knee and ankle pain after another slip and fall... all three work. comp were for different employers... so she is turning this into quite the source of income for her...

work. comp. is BOGUS - if a piece of equipment falls onto you that you were operating then fine.... but if you hurt your neck because you turned your head around when somebody called your name, or you hurt your back because you decided to kick a heavy box - then those injuries (that could have occured just as easily at home), should not be work. comp... i have one guy who filed work. comp because he is STRESSED out by his responsibilities...

sigh... please let me know i am not the only one seeing this crap

 

[Rhizo]

You're not alone. My first month in practice I got asked if I would do IME's. I refused, and it hasn't come up since. I don't like caring for the majority of the work comp patients anymore than the next physician. The problem is, as ridiculous as some of the patients are, the comp people are often even more ridiculous (an example of which documented above by tenesma).

As the patient's physician (as opposed to an IME, in which it's very clearly stated that they are not acting as the patient's physician), I think I have to give the patient the benefit of the doubt, and act as their advocate. It doesn't mean you have to advocate BS. I usually give them work restrictions for a defined time period, make sure they get appropriate care, and when I've done what can do send them for an FCE. Anybody with a different approach, I'd love to hear it...I struggle with this stuff. You don't spend much time learning about disability schedules and dealing with lawyers and QRCs in training...

 

[ghost dog]

You're not alone. My first month in practice I got asked if I would do IME's. I refused, and it hasn't come up since. I don't like caring for the majority of the work comp patients anymore than the next physician. The problem is, as ridiculous as some of the patients are, the comp people are often even more ridiculous (an example of which documented above by tenesma).

As the patient's physician (as opposed to an IME, in which it's very clearly stated that they are not acting as the patient's physician), I think I have to give the patient the benefit of the doubt, and act as their advocate. It doesn't mean you have to advocate BS. I usually give them work restrictions for a defined time period, make sure they get appropriate care, and when I've done what can do send them for an FCE. Anybody with a different approach, I'd love to hear it...I struggle with this stuff. You don't spend much time learning about disability schedules and dealing with lawyers and QRCs in training...

I think the mental health professionals will have to play a larger role in this issue in the future. The type of "injuries" Tenesma describes are clearly not of sufficient magnitude to cause the lasting disability that is claimed by their patients. Ignoring a patients complaints won't make them go away (as we all know).

Perhaps psychiatrists or psychologists should do IMEs?

An educated guess here: the patient who slipped on the floor - She has fibromyalgia because of this injury? ( I see these ALL THE TIME!!)

 

[drusso]

The trick to doing the comp and IME stuff is to understand a few fundamental stipulations about how the system works:

a) Comp insurance is not health insurance in the way most people think about it---it's societal injury/risk liability financing. Therefore, your job role as a physician is different. You're less of a "physician" per se and more of a medical umpire or medical juror of fact: Is this injury work related? Are there permanent impairments as a result of their accepted condition? Is the patient medically stationary? etc.

Your job is sort of to call "ball or strike" in a manner that is fair to both injured workers (no one calls them "patients" in comp; they're either "claimants" or "injured workers") and the financers of those paying for the "treatment" of their injury. I explain this to patients from the get go.

I explain that I have an ethical obligation to treat them in a manner consistent with the best available medical practice (most comp insurance policy simply don't offer all available treatment options) and a fudiciary obligation to the comp system and to society as a whole (who do you think is paying for this??). I explain further that there are inherent conflicts of interest, competing stakeholders, and incomplete scientific evidence upon which to base most of the decisions I will be making about their injury, their capacity to return to work and function in society, and the medical basis for the compensability of their injuries.

They may disagree with my judgment in which case there are omsbudsmen, arbiters, medical directors, medical decision review panels, IME's, lawyers, etc as available resources to them. I often get the sense that I'm the first doctor to explain this to them. I then further explain that my general guiding principle is that comp is "crazy making" for workers and doctors and the best thing do do is to move the process along as expeditiously as possible before they end up resembling those individuals in item "d" below. This can usually be measured in a geological time scale given the way most comp systems work.

b) Comp is less concerned about workers per se, and they are more concerned with the risk/liability and expenses related to their conditions. From a comp perspecitve, it is merely a coincidence that the injury resides inside of an actual human being.

c) Early in the course of an injury what doctors have to say is important. As injuries become more chronic, doctors don't call the shots any longer in comp, but case managers, administrative law judges, and lawyers do. Given the nature of my practice, I tend to see patients rather "late in the game" so I explain that what I have to say is pretty easy for their insurance company to ignore.

d) Some injured workers end up becoming very angry with the comp system, develop "compensation neuroses" or display other bizarre behavior as a consequence of their hostility, learned helplessness, and general state of demoralization with the comp system and their employer. So, I don't take it personally.

e) Finally, the comp system is filled with ******: Plaintiff ******, defendant ******, industry ******, insurance company ******, state ******, federal ******, inter-galatical ******, patient advocacy ******, etc. Try to piss everyone off just a little bit every time and you'll develop a nice reputation for being "fair and balanced."

 

[Disciple]

An educated guess here: the patient who slipped on the floor - She has fibromyalgia because of this injury? ( I see these ALL THE TIME!!)

Good thing Fibromyalgia is not ratable via the AMA Guides.

 

[Disciple]

Perhaps psychiatrists or psychologists should do IMEs?

They do.

Usually for "stress" claims though.

A psyche IME may be involved in a chronic pain case for issues of apportionment, if the treating physician detects psychological overlay and recomends cognitive behavioral therapy, but the insurer claims the depression/anxiety was prexisting.

 

[ghost dog]

They do.

Usually for "stress" claims though.

A psyche IME may be involved in a chronic pain case for issues of apportionment, if the treating physician detects psychological overlay and recomends cognitive behavioral therapy, but the insurer claims the depression/anxiety was prexisting.

What a load of crap. If anyone has severe chronic constant pain, they WILL develop anxiety and depression. The question is to the degree and extent. HOWEVER, differentiating between organic and psychogenic pain is close to "mission impossible" when it comes to chronic pain.

 

[Disciple]

Most insurers will let you refer for a psyche consult and a little Cognitive Behavioral Therapy.

If it turns into long-term Psychiatric care, +SSRIs, other costly meds, etc., the insurer will start to hedge, and, enter the Psyche IME.

 

[PMR 4 MSK]

Most insurers will let you refer for a psyche consult and a little Cognitive Behavioral Therapy.

If it turns into long-term Psychiatric care, +SSRIs, other costly meds, etc., the insurer will start to hedge, and, enter the Psyche IME.

I've had the opposite experience - most adjustors go virtually apoplectic at the very mention of pschological issues and will immediately get an IME to shut the patient down.

'Hired Guns' get their reputation by being for the insurance industry, and against the patient, creating a positive cycle of more and more referals.

I can't count how many times a patient has told me the IME doc came in the room, asked 1 or 2 questions, asked them to stand up and bend forward, and then left the room. Now this is just the patients speaking, but when you hear this time and time again, coming from different patients in different parts of the country, you start wonderng if it is true.

I agree with OP that ortho's tend to much more favor the insurance company.

Its easy to tell who doesn't want to work simply by not taking them off work. Always give restrictions only, never take a patient off work unless the are hospitalized. If their company has a policy of accomodating any restriction, they will get them in the work place. Then when the patient keeps coming up with reasons why it isn't working - they're not staying within his restrictions, he cant drive to work, he can't sit that long, etc, you have someone with entitlementiasis, who wants to stay home, get paid, take vicodin all day and watch Oprah while he feels sorry for himself or generates either sympathy or admiration from his family.

 

[ghost dog]

I've had the opposite experience - most adjustors go virtually apoplectic at the very mention of pschological issues and will immediately get an IME to shut the patient down.

'Hired Guns' get their reputation by being for the insurance industry, and against the patient, creating a positive cycle of more and more referals.

I can't count how many times a patient has told me the IME doc came in the room, asked 1 or 2 questions, asked them to stand up and bend forward, and then left the room. Now this is just the patients speaking, but when you hear this time and time again, coming from different patients in different parts of the country, you start wonderng if it is true.

I agree with OP that ortho's tend to much more favor the insurance company.

Having reviewed my IMEs , I found that 27 % of my cases where medically unable to work at the time of assessment.

How does my figure of 27 % compare to everyone else's figures? I don't feel like a "hired gun", as I try very hard to be as fair as possible. I spend as much time (if not more) with these IME cases as I do with a chronic pain consult.

 

[Disciple]

Applicant (patient) attorneys use hired guns as well.

That's part of the problem, each side gets their own IME(s), which can drag on the process on for years until it's eventually settled in court.

 

[ghost dog]

Applicant (patient) attorneys use hired guns as well.

That's part of the problem, each side gets their own IME(s), which can drag on the process on for years until it's eventually settled in court.

I have never had a patient in an IME come across as feeling "cheated" or poorly treated in any manner. Usually it's the opposite. I'm frequently the first doctor who's given them a concrete diagnosis and list of possible treatments to follow up on.

 

[Disciple]

I'm not saying you're a hired gun.

Just how the system tends to draw things out, helping patients to get worse, and angry.

Where I practice they used to call it "deuling IMEs".

 

[Mister Mxyzptlk]

The real question is: "Why do you continue to torture yourselves with W/C?"

 

[Tenesma]

i would love to drop out of w/c

1) not very gratifying

2) feels like up-hill battle with both the adjuster (who doesn't want to authorize/pay) and the patient (who doesn't necessarily want to work, and rarely admits pain relief)

3) their reimbursements are really not that impressive (10% over medicare for me)

--- will there be a backlash in my community if i continue to drop out of insurance plans... while it may be financially smart, will it upset PCPs/Orthos?

 

[PMR 4 MSK]

The real question is: "Why do you continue to torture yourselves with W/C?"

Because they pay me 1.5 x private insurance and 2 x Medicare in the clinic, 2 - 3 x privates and upwards of 10 x Medicare in fluoro, and 2 - 3 x privates and 4 x Medicare in EMG.

Work Comp here is nowhere near as bad as Texas. It pays well, with less hassels and less paperwork. It's still often a fight, but the rewards of winning are well worth it.

 

[ghost dog]

Because they pay me 1.5 x private insurance and 2 x Medicare in the clinic, 2 - 3 x privates and upwards of 10 x Medicare in fluoro, and 2 - 3 x privates and 4 x Medicare in EMG.

Work Comp here is nowhere near as bad as Texas. It pays well, with less hassels and less paperwork. It's still often a fight, but the rewards of winning are well worth it.

Wow. That's a huge difference in payment scedules! But the real question is, what PERCENTAGE of w/c patients show up for appointments and procedures? No shows are a REAL PAIN IN THE ASS (as we all know - particularly when procedures are booked - that punches a nice big hole in your schedule).

Since I work in Canada, I'm not familiar with your system. Are these w/c patients penalized if they fail to show up for their treatment plan?

GD.

 

[PMR 4 MSK]

Wow. That's a huge difference in payment scedules! But the real question is, what PERCENTAGE of w/c patients show up for appointments and procedures? No shows are a REAL PAIN IN THE ASS (as we all know - particularly when procedures are booked - that punches a nice big hole in your schedule).

Since I work in Canada, I'm not familiar with your system. Are these w/c patients penalized if they fail to show up for their treatment plan?

GD.

It's rare for me to have no-shows. It's the public aid pts who no-show - the one's I don't get paid much/at all for anyway.

If they don't show it's a huge black mark against them, and they risk losing their claim without extenuating circumstances, or a good lawyer.

 

[Mister Mxyzptlk]

I opted out of WC when rates were 160% of Medicare. There's some s_hit I just won't eat.

 

[Tenesma]

gorback - how did that affect your referring docs when you dropped w/c?

 

[mille125]

The real question is: "Why do you continue to torture yourselves with W/C?"

this is my question as well...i dont see any and my life is much simpler

 

[mille125]

i would love to drop out of w/c

1) not very gratifying

2) feels like up-hill battle with both the adjuster (who doesn't want to authorize/pay) and the patient (who doesn't necessarily want to work, and rarely admits pain relief)

3) their reimbursements are really not that impressive (10% over medicare for me)

--- will there be a backlash in my community if i continue to drop out of insurance plans... while it may be financially smart, will it upset PCPs/Orthos?

no...

 

[mille125]

I opted out of WC when rates were 160% of Medicare. There's some s_hit I just won't eat.

it was 125% of medicare when I entered...BRIEFLY

now it is supposedly 150-175% of medicare. however interestingly enough, a lot of contracts from carriers come back at 80-85% of WC fee schedule...what a barrow of laughs....

i have been free for 2 yrs and freedom has never tasted so good. many of the orthos/PCPS have left the system as well....

 

[Mister Mxyzptlk]

gorback - how did that affect your referring docs when you dropped w/c?

They were jealous.

 

[Doctodd]

was that IME guy named Cianca?

 

[brori]

I believe gorback is referring to an ortho in the Houston area. Rhymes with "starry seaman". IMEs used to have the impenetrable force field of "no physician/patient relationship established". However, there have been some chips in the armor.

My two cents. As a doctor, it is our nature to give people the benefit of the doubt and to act as a patient advocate. Without viewing a DVD of a patient's physical behaviour outside of our clinic, it is near impossible to accurately assess some patient's true functional capacity. FCE's are the best measure we have (trouble). We don't have pain thermometers or use lie detectors. For many IME patients, it boils down to judgment and experience.

I have met practicing physicians who have suffered severe strokes, spinal cord injuries, and multiple sclerosis. On the other hand, I've met a few 30somethings on total disability for fibromyalgia/"nebulous seizure-like syndrome"


All being said, I've given my share of sedentary work recommendations.
Jealous

 

[brori]

Damn, not done yet.

The problem with WC starts the second the worker reports the injury. Someone (usually non medical) makes the initial eval and documents the injury. This diagnosis will stay with the patient (or as they would like us to say "claimant") forever.

The trend now in Texas is for the carrier to get a designated doctor exam ASAP. As stated previously there are DDEs who consistently get the patient MMIed right away.

The now and future: I've heard that large insurance carriers (Coventry for example) are now mandating that the treating physician be either internal med, FP, or "board certified" occupational med. That's right---no PMR or ortho (unless you fork over the $900 to sit for the enlightening ACOEM course and the additional $900 to take the exam to certify you as "occupational med"). Great for Concentra and CareNow upper management.

still jealous

 

[Mister Mxyzptlk]

Treating physician for TX WC has to be the worst job in medicine. I am not sure that the carriers can exclude other specialties if state law says those other specialties can serve as treating physician.

TX docs need to vote with their feet and refuse to accept WC patients until there is true reform, not just the same old rotten system behind a facade of "reform".

 

[ghost dog]

I believe gorback is referring to an ortho in the Houston area. Rhymes with "starry seaman". IMEs used to have the impenetrable force field of "no physician/patient relationship established". However, there have been some chips in the armor.

My two cents. As a doctor, it is our nature to give people the benefit of the doubt and to act as a patient advocate. Without viewing a DVD of a patient's physical behaviour outside of our clinic, it is near impossible to accurately assess some patient's true functional capacity. FCE's are the best measure we have (trouble). We don't have pain thermometers or use lie detectors. For many IME patients, it boils down to judgment and experience.

I have met practicing physicians who have suffered severe strokes, spinal cord injuries, and multiple sclerosis. On the other hand, I've met a few 30somethings on total disability for fibromyalgia/"nebulous seizure-like syndrome"


All being said, I've given my share of sedentary work recommendations.
Jealous

Hi,

Do you refer to patients with pseudoseizures when you mentioned the "nebulous seizure-like syndrome" ?

I've seen a few of these.

Curious.

 

[brori]

I believe they are psychogenic or pseudoseizures. Patient will often report distant seizure-like episode. Was placed on meds, but doesn't take them anymore (didn't like side effects). Never had EEG, let alone a sleep deprived video monitored EEG.

 

[ghost dog]

I believe they are psychogenic or pseudoseizures. Patient will often report distant seizure-like episode. Was placed on meds, but doesn't take them anymore (didn't like side effects). Never had EEG, let alone a sleep deprived video monitored EEG.

I referred a patient to neurology who was having seizures vs pseudoseizures while on Topamax AND Gabapentin. She had a normal ambulatory EEG and sleep deprived EEG. She actually had a "seizure episode" and fell down during the ambulatory EEG - COMPLETELY normal reading.

Patients with pseudoseizures can be VERY convincing - this patient had an episode in my office, and appeared so genuine I called an ambulance for her.

After extensive neuro follow-up, the neurologist was convinced she had pseudoseizures. She also had a history of fibromyalgia, sexual abuse and chronic tension type headache.

GD.

 

[stim4u]

during fellowship, I took care of a young athlete diagnosed with CRPS after a sports injury. After a sympathetic block in the OR, the patient had a 'seizure' in the PACU that appeared quite real. After a neuro consult and repeated seizures, the neuro taught me something quite neat..... Try to open the patient's eyes during the 'seizure', if they resist it is unlikely a true seizure(bogus).

So, immediately after forcing her eyes open, her seizures broke, and she was magically better, and was discharged home..... Lots of psychopathology with CRPS and pseudoseizures....

 

[ghost dog]

during fellowship, I took care of a young athlete diagnosed with CRPS after a sports injury. After a sympathetic block in the OR, the patient had a 'seizure' in the PACU that appeared quite real. After a neuro consult and repeated seizures, the neuro taught me something quite neat..... Try to open the patient's eyes during the 'seizure', if they resist it is unlikely a true seizure(bogus).

So, immediately after forcing her eyes open, her seizures broke, and she was magically better, and was discharged home..... Lots of psychopathology with CRPS and pseudoseizures....

Thanks for the tip. I'll keep this in mind.

GD.

 

[dejerine]

tenesma

As before, the post of IME by you is very apt. Orthos can be just unbelievable in the casual way they practice.

First Case.

I am familiar with a case where the patient went to the ER after a fall. The ankle was swollen and the foot rocker bottom with blood. The ER films were AP and lateral and omitted obliques. The film was poorly penetrated. The patient was told nothing was broken and sent home. With peristent pain the patient went to a University orthopedist who took the Xray report from the referring hospital for what it was worth. The patient continued to have severe pain. Finally the patient went to UCSF where NINE fractures were found on CT. The patient got avascular necrosis in the subtalar region and will be crippled for life. Another orthopod did an IME and said he thought the injury was self inflicted because it was impossible to fracture that badly falling off two steps. Now what can we do for this person, who was let down by the medical system. The patient should have gone to a pain center, who a little more humbly would have BELIEVED the patient. My anesthesiology chairman, world famous, used to say SIXTY PERCENT of being a real doctor is being able to tell is someone is sick. The mere mention of request for disability is enough to send many Orthopods running, provided they do not peronally have avascular necrosis of the talar bone.

Second case,

an orthopedist, different from above, set my kid's arm radial fracture off 22 degrees. This same orthopod was hauling in money right and left for doing IME's for an insurance company. One day in court, the judge said to him, "I have seen you before and you always say the patient is okay. You have no integrity and are a ***** of the court. I am barring you from ever testifying in court again in this state". The percentage of his practice earned from IME's was revealed by the fact he had to leave town after he lost his job as parrot for the insurers.

Third case

Teenage girl working for amusement park had her arm torn off by the machinery for a kid's ride. She asked for worker's comp. An orthopod, none of the above, appeared and said her acts were so grossly negligent it was her fault and that in the computer age, with eye tracking equipment, she was zero disability. Believe it or not, that is exactly how the court ruled. One arm mssing. No disability and no worker's comp. Has phantom pain.

My take on IME's from orthopods. The insurers know what they are doing and so do the orthopods.

P.S. I happen to have an excellent orthopod in Cleveland who could not be better and will go to bat for his patients.

 

[ghost dog]

tenesma

As before, the post of IME by you is very apt. Orthos can be just unbelievable in the casual way they practice.

First Case.

I am familiar with a case where the patient went to the ER after a fall. The ankle was swollen and the foot rocker bottom with blood. The ER films were AP and lateral and omitted obliques. The film was poorly penetrated. The patient was told nothing was broken and sent home. With peristent pain the patient went to a University orthopedist who took the Xray report from the referring hospital for what it was worth. The patient continued to have severe pain. Finally the patient went to UCSF where NINE fractures were found on CT. The patient got avascular necrosis in the subtalar region and will be crippled for life. Another orthopod did an IME and said he thought the injury was self inflicted because it was impossible to fracture that badly falling off two steps. Now what can we do for this person, who was let down by the medical system. The patient should have gone to a pain center, who a little more humbly would have BELIEVED the patient. My anesthesiology chairman, world famous, used to say SIXTY PERCENT of being a real doctor is being able to tell is someone is sick. The mere mention of request for disability is enough to send many Orthopods running, provided they do not peronally have avascular necrosis of the talar bone.

Second case,

an orthopedist, different from above, set my kid's arm radial fracture off 22 degrees. This same orthopod was hauling in money right and left for doing IME's for an insurance company. One day in court, the judge said to him, "I have seen you before and you always say the patient is okay. You have no integrity and are a ***** of the court. I am barring you from ever testifying in court again in this state". The percentage of his practice earned from IME's was revealed by the fact he had to leave town after he lost his job as parrot for the insurers.

Third case

Teenage girl working for amusement park had her arm torn off by the machinery for a kid's ride. She asked for worker's comp. An orthopod, none of the above, appeared and said her acts were so grossly negligent it was her fault and that in the computer age, with eye tracking equipment, she was zero disability. Believe it or not, that is exactly how the court ruled. One arm mssing. No disability and no worker's comp. Has phantom pain.

My take on IME's from orthopods. The insurers know what they are doing and so do the orthopods.

P.S. I happen to have an excellent orthopod in Cleveland who could not be better and will go to bat for his patients.

I'm not a religious man (by any stretch of the imagination) but if there is a hell, there will be a special place in it reserved for these orthopods!!
*******s.

 

[ampaphb]

tenesma

As before, the post of IME by you is very apt. Orthos can be just unbelievable in the casual way they practice.

First Case.

I am familiar with a case where the patient went to the ER after a fall. The ankle was swollen and the foot rocker bottom with blood. The ER films were AP and lateral and omitted obliques. The film was poorly penetrated. The patient was told nothing was broken and sent home. With peristent pain the patient went to a University orthopedist who took the Xray report from the referring hospital for what it was worth. The patient continued to have severe pain. Finally the patient went to UCSF where NINE fractures were found on CT. The patient got avascular necrosis in the subtalar region and will be crippled for life. Another orthopod did an IME and said he thought the injury was self inflicted because it was impossible to fracture that badly falling off two steps. Now what can we do for this person, who was let down by the medical system. The patient should have gone to a pain center, who a little more humbly would have BELIEVED the patient. My anesthesiology chairman, world famous, used to say SIXTY PERCENT of being a real doctor is being able to tell is someone is sick. The mere mention of request for disability is enough to send many Orthopods running, provided they do not peronally have avascular necrosis of the talar bone.

Second case,

an orthopedist, different from above, set my kid's arm radial fracture off 22 degrees. This same orthopod was hauling in money right and left for doing IME's for an insurance company. One day in court, the judge said to him, "I have seen you before and you always say the patient is okay. You have no integrity and are a ***** of the court. I am barring you from ever testifying in court again in this state". The percentage of his practice earned from IME's was revealed by the fact he had to leave town after he lost his job as parrot for the insurers.

Third case

Teenage girl working for amusement park had her arm torn off by the machinery for a kid's ride. She asked for worker's comp. An orthopod, none of the above, appeared and said her acts were so grossly negligent it was her fault and that in the computer age, with eye tracking equipment, she was zero disability. Believe it or not, that is exactly how the court ruled. One arm mssing. No disability and no worker's comp. Has phantom pain.

My take on IME's from orthopods. The insurers know what they are doing and so do the orthopods.

P.S. I happen to have an excellent orthopod in Cleveland who could not be better and will go to bat for his patients.

1) a fracture that severe in that location would most likely have gone on to AVN regardless

2) There are ****** in every specialty - the pigs in our field who do bilateral L1/2 - L5/S1 facets or TFEs routinely are not limited, and will continue raping the system as a result. Also, the judge so grossly over-stepped his bounds the way you describe the facts that, had I been the orthopod, I would have immediately reported him to the judicial; review panel. There are plantiff's and defense docs in every juresdiction - whether tey are to be believed is a matter for the jury to decide.