Question about forensic work

[liquidshadow22]

How often does one agree to perform a forensic evaluation and form a conclusion that does not support the attorney who is paying for your services? I assume most psychiatrists would not do this because let's be honest it won't increase their likelihood of being hired again. Also, it's hard as a psychiatrist to know exactly what you're getting yourself involved in until you actually perform the evaluation. Is it possible to really be impartial in your evaluation?

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[Bartelby]

It's not that unusual. Keep in mind:

1 - Your reputation matters, and attorneys can find your old depositions, testimony transcripts, etc. If you're a hired gun, people will know it. That will make you worth far less to attorneys in the long run.
2 - If you just tell attorneys what they want to hear, and you produce flimsy opinions, those opinions may very well fall apart on cross-exam. Having the opinion fail at trial or deposition (after your side's attorney already built a case relying on it) is WAY worse than just being honest with a disappointing opinion up front.
3 - Knowingly lying under oath is incredibly sleazy (not to mention illegal), if that were really required to bring in cases most psychiatrists would take a multitude of other well-paid options instead.

I think the adversarial system inherently produces some degree of bias, but most of the forensic people I've met seem to me to be working in good faith.

 

[JKinSC]

Disclaimer: I’m not a forensics guy, but...

An honest evaluation is appreciated far more than playing to whoever pays you. One of the forensic attendings in my residency program told us that he was occasionally retained for cases, solely so that the other side couldn’t hire him.

 

[romanticscience]

How often does one agree to perform a forensic evaluation and form a conclusion that does not support the attorney who is paying for your services? I assume most psychiatrists would not do this because let's be honest it won't increase their likelihood of being hired again. Also, it's hard as a psychiatrist to know exactly what you're getting yourself involved in until you actually perform the evaluation. Is it possible to really be impartial in your evaluation?

You try and work with the attorney to not go so far that you become unhelpful. This is at least how I practice.

Before commencing on the full evaluation, there's usually a discussion with the attorney about the basic details of the case.

At this point, and sometimes with the help of some records, I speak with the attorney about my general thoughts about the case. If I feel that I'm likely to render a differing opinion, I give the attorney the option to stop there. However, others may want you to do the eval anyway. It helps to set the expectations early.

Sometimes, after doing your evaluation and talking it over with the attorney, they won't have you write a report because it won't be helpful for their case. This is why I hate working with third party brokers/agencies because they are an obstacle to the working relationship with the attorney.

 

[TexasPhysician]

Attorneys only want cases that will win or unethically to drag them out forever to get more $ on hourly rates.

Honesty helps them prep to win or cut bait for better cases. Either way, they win with honesty.

Unethically - If they are billing by the hour, they will want to hear all of your honesty to keep billing and then maybe get referrals to honest friends so that they can continue the neverending quest for an “ideal” expert. The hope would be to never find one and continue to “develop” the case.

 

[Stagg737]

You try and work with the attorney to not go so far that you become unhelpful. This is at least how I practice.

Before commencing on the full evaluation, there's usually a discussion with the attorney about the basic details of the case.

At this point, and sometimes with the help of some records, I speak with the attorney about my general thoughts about the case. If I feel that I'm likely to render a differing opinion, I give the attorney the option to stop there. However, others may want you to do the eval anyway. It helps to set the expectations early.

Sometimes, after doing your evaluation and talking it over with the attorney, they won't have you write a report because it won't be helpful for their case. This is why I hate working with third party brokers/agencies because they are an obstacle to the working relationship with the attorney.

Can you elaborate a biton third party brokers or agencies? How would this work in the forensics world in terms of communication with the legal team and pay? Do they just get you connected or do they continue to remain the middle man even after retaining you?

 

[PsyDr]

The unspoken rule is two. Attorneys will give you one instance of not giving them the opinion they want. After the second, they will use another expert.

If you're in demand, it doesn't matter.

 

[romanticscience]

Can you elaborate a biton third party brokers or agencies? How would this work in the forensics world in terms of communication with the legal team and pay? Do they just get you connected or do they continue to remain the middle man even after retaining you?

Some companies liaise with law firms to limit the overall fees. So, you'll be retained to "do an IME" and you communicate/bill through this company. This is annoying if you want to speak with the attorney directly. The one I worked with "said" they just act as the middle man for the "IME" part and then they cut you loose with anything above or beyond (deposition, court appearance, etc). Problem is, "doing an IME" isn't always that simple. Hope this helps!

 

[Stagg737]

Some companies liaise with law firms to limit the overall fees. So, you'll be retained to "do an IME" and you communicate/bill through this company. This is annoying if you want to speak with the attorney directly. The one I worked with "said" they just act as the middle man for the "IME" part and then they cut you loose with anything above or beyond (deposition, court appearance, etc). Problem is, "doing an IME" isn't always that simple. Hope this helps!

It does, thank you! So for the IME, is that still an hourly rate or is it a flat fee like insurance IME’s in other areas of medicine? Is there a significant OT difference when going through an agency than working straight with the lawyers?

 

[romanticscience]

It does, thank you! So for the IME, is that still an hourly rate or is it a flat fee like insurance IME’s in other areas of medicine? Is there a significant OT difference when going through an agency than working straight with the lawyers?

I've worked for some companies that ask you for a flat fee for the IME. This is tricky because they get the money from the client up-front and can't get any more later (this sucks if you need to make significant revisions to the report after submission). So, I guess it's per hour for you (if you're good at estimating your work) but flat for the other party. Most times I've worked with an agency, it's been for disability. I'm staying away from those requests for a few reasons: Nature of the disability evaluations (to do it right takes time and people hate when you say they aren't fully disabled), and headaches working with the companies, and the minimal difference in rate compared to my clinical work.

 

[WisNeuro]

I've worked for some companies that ask you for a flat fee for the IME. This is tricky because they get the money from the client up-front and can't get any more later (this sucks if you need to make significant revisions to the report after submission). So, I guess it's per hour for you (if you're good at estimating your work) but flat for the other party. Most times I've worked with an agency, it's been for disability. I'm staying away from those requests for a few reasons: Nature of the disability evaluations (to do it right takes time and people hate when you say they aren't fully disabled), and headaches working with the companies, and the minimal difference in rate compared to my clinical work.

There are plenty of IME companies where you give them your fee schedule and they set up everything with the referral source. I don't have to sacrifice anything on my side money-wise. They contact me when they have a case, with some basic details and timeline, I accept if I want it, give some dates and times, and I get paid shortly after I give them the report. I'm not personally a fan of flat fee per case, as the cases vary quite a bit in term of complexity and how much review you have to do with records, at least if you're doing it the right way.

 

[ArdorAyurveda]

Does an IME for forensic work involve a comprehensive physical exam in addition to a psychiatric exam?

 

[WisNeuro]

Psychiatrist is not going to do a physical exam. Internist might do one if indicated. As a forensic neuropsychiatrist I might do a neurological examination but most of the time my exam is going to be focused on the neurobehavioral. Depending on the case you might have the plaintiff's attorney hovering all over you and limiting the scope of your exam anyway. I haven't listened to a pt's heart and lungs since I was 4th yr resident, it would be inappropriate for me to do so during a forensic examination.

You guys allow third party observers during an exam?

 

[PsyDr]

Psychiatrist is not going to do a physical exam. Internist might do one if indicated. As a forensic neuropsychiatrist I might do a neurological examination but most of the time my exam is going to be focused on the neurobehavioral. Depending on the case you might have the plaintiff's attorney hovering all over you and limiting the scope of your exam anyway. I haven't listened to a pt's heart and lungs since I was 4th yr resident, it would be inappropriate for me to do so during a forensic examination.

How in the hell is the attorney limiting the scope of your examination?!

 

[splik]

How in the hell is the attorney limiting the scope of your examination?!

It happens. Most of the time it doesn’t and there is no one present but opposing counsel (usually plaintiff attorney) can and does. I’m guessing the reason this doesn’t happen for neuropsychologists is the integrity of the testing and environment would be clearly compromised. That said it is increasingly common for attorneys to request a list of tests to be used prior to the exam which is very problematic of course but this is going to become even more common

 

[PsyDr]

It happens. Most of the time it doesn’t and there is no one present but opposing counsel (usually plaintiff attorney) can and does. I’m guessing the reason this doesn’t happen for neuropsychologists is the integrity of the testing and environment would be clearly compromised. That said it is increasingly common for attorneys to request a list of tests to be used prior to the exam which is very problematic of course but this is going to become even more common

1) Initially, neuropsychology became interested in the effects of third party observers in clinical work. The effects of a third party are easily understood by anyone who has asked a patient about a sensitive matter in front of their spouse. On both interview, and testing, a clear body of literature developed that showed that third party observers have a DRASTIC effect on both interview and testing. In forensics, third party observers and tape recording were shown to have a significant effect on both testing and interview. This has provoked policy statements by the American Psychological Association, National Academy of Neuropsychology, etc. This is not limited to psychology, as there is some 30 years of publications about this subject in forensic psychiatry. The American Journal of Psychiatry, the Journal of American Academy of Psychiatry and Law, and the American Bar Association have also put forth guidelines about this subject which minimally urge extreme caution, if not prohibition. That being said, third party observers affect the evaluation in such a manner as to potentially invalidate the exam. If the attorney is limiting the examiner's line of questioning, I would argue that the examiner was unable to adhere to diagnostic guidelines, as the DSM5 requires one to rule out alternative explanations. I would also argue that any examiner who failed to at least acknowledge the substantial effects of third party examiners, and the effects there, is not great.

2) The ONLY reason that third party observers happen, is that examiners allow it. Some people are unaware of the effects of third party observers, think it doesn't matter, and proceed because it is easier.

 

[nexus73]

It happens. Most of the time it doesn’t and there is no one present but opposing counsel (usually plaintiff attorney) can and does. I’m guessing the reason this doesn’t happen for neuropsychologists is the integrity of the testing and environment would be clearly compromised. That said it is increasingly common for attorneys to request a list of tests to be used prior to the exam which is very problematic of course but this is going to become even more common

A neuropsycologist I talked to said he allowed attorneys to be present if they insisted, but required them to be be silent and sit off in the corner, or he would stop the evaluation. Mostly this was for return to work, fitness for duty evaluations.

 

[WisNeuro]

A neuropsycologist I talked to said he allowed attorneys to be present if they insisted, but required them to be be silent and sit off in the corner, or he would stop the evaluation. Mostly this was for return to work, fitness for duty evaluations.

I think CA is pretty lax with this and can allow it, despite attempts to quash. The examiner can still refuse to do the case at all, which is what I would suggest. I'd be surprised if the person you spoke to is boarded. Fortunately, in my state, every boarded neuropsych has refused to allow observers or recording in any of our IME exams. So, if an attorney wants/needs an exam from a boarded individual, they have to drop that particular intimidation tactic.

 

[liquidshadow22]

Is there a certification one should pursue to perform IMEs thru ABIME to become a QME?is this mandatory? Is separate licensure needed for each state of practice? There are companies that will hire you but I see they want to take 40% of whatever you are paid. They pay for your certification and marketing etc. Better to just obtain certification on your own and market yourself?

 

[liquidshadow22]

Are any of the training certificates mandatory /worth it for disability evaluations eg AMA?

 

[psyguru]

Are any of the training certificates mandatory /worth it for disability evaluations eg AMA?

They maybe worth it if you plan on doing a lot of them and are not boarded in forensics. I am board certified in forensics and don't do enough disability exams to warrant it. The ones (social security) that require AMA ratings usually don't seem to pay as well and are less interesting to me than the cases I usually do. I find my BIM board certification and MRO are likely more valuable than QME or ABIME. But I have the forensics board which maybe redundant and trump the QME.

In regards to your previous post, 40% cut is high but I would pursue both...your own cases and from the third part company taking 40%. You can always turn down the ones with a 40% cut when you have others without a cut. Some of the 3rd party companies will add on to your requested rate. I obtain plenty of referrals so would not be interested in those with 40% cut.

 

[WisNeuro]

They maybe worth it if you plan on doing a lot of them and are not boarded in forensics. I am board certified in forensics and don't do enough disability exams to warrant it. The ones (social security) that require AMA ratings usually don't seem to pay as well and are less interesting to me than the cases I usually do. I find my BIM board certification and MRO are likely more valuable than QME or ABIME. But I have the forensics board which maybe redundant and trump the QME.

In regards to your previous post, 40% cut is high but I would pursue both...your own cases and from the third part company taking 40%. You can always turn down the ones with a 40% cut when you have others without a cut. Some of the 3rd party companies will add on to your requested rate. I obtain plenty of referrals so would not be interested in those with 40% cut.

If you don't want to deal with the billing/collecting from law firm side of things, as you said, there are plenty of companies that have their own add ons. As in you give them your fee schedule for services and they have it on offer to firms that need the eval, they don't cut into any of your fees. 40% cut is super steep.

 

[whopper]

I just got tossed off a case for this very reason.

I was actually glad. Made a lot and the work I did up to that point easy. Had I stayed on it would've entered the tough zone phase. Of course I didn't give my opinion with that intent.

Long story-I offered an excellent defense for one physician but it put the blame more so on another physician. The other physician was giving the patient large amounts of Xanax with very inappropriate comments about it. That other physician was being represented by a different attorney in the same firm. Despite that lawyers are supposed to be specifically for their client and not do things to protect the other client at the cost of their own client this lawyer's boss told him to drop me.

After I was dropped the lawyer told me he thought I was right and would keep me in mind.

Yes I perfectly know very well the firm is doing something they're not supposed to do.

 

[psyguru]

If you don't want to deal with the billing/collecting from law firm side of things, as you said, there are plenty of companies that have their own add ons. As in you give them your fee schedule for services and they have it on offer to firms that need the eval, they don't cut into any of your fees. 40% cut is super steep.

It's not too difficult to collect from law firms. Use a fee schedule and retainer contract. Get the money upfront. If you this regularly enough, set up a s-corp for tax reasons.

 

[WisNeuro]

It's not too difficult to collect from law firms. Use a fee schedule and retainer contract. Get the money upfront. If you this regularly enough, set up a s-corp for tax reasons.

At the moment, most of my IME work comes through intermediaries, they handle everything in terms of billing, scheduling, and contact between parties. I'll probably eventually move to completely solo, but this has been nice as I also fully transition into PP in the clinical realm as well.