The Independent Medical Examiner

Many patients have questions regarding an IME (Independent Medical Exam). These questions usually come from upset patients who question the process. I never know what to say, but I recently read an article by John Gould, who couldn't have described the process any clearer. Some of the things he said were, and I quote: This is a touchy subject. The independent medical examiner is a doctor working on a short- or long-term contract for a worker's compensation case. In its purest, most legitimate form, this arrangement provides a second opinion by an alleged expert in a case in which the response to treatment seems delayed. This review is to ensure that the patient and the insurance company are receiving fair and appropriate treatment by the attending physician. Certainly, this is reasonable. In many cases, however, it seems that inappropriate treatment, is being rendered by the insurance company and the independent examiner, either innocently or otherwise.

Who are the physicians who work as examiners, and what are they up to? In my experience, they have been orthopedic fellows, barely out of residency, older orthopedists who have retired or are phasing down their practice, or young orthopedists early in their practice, which is often in academics. All need the money and are aware of the built-in potential for bias: the more that the reports they provide save the insurance company money, the more referrals they will receive. It doesn't take a genius to understand this picture.

My experiences are as follows: Our orthopedic fellows have made good moonlighting money reviewing these cases. For these fellows to suggest that some good doctors in our referral base might not be providing appropriate care, particularly considering the fellow's lack of experience in managing patients, could not possibly strengthen our referrals from these individuals. I forbade this practice among my fellows for both moral -and practical reasons. I also discouraged young attending's from spending their time salting away "secret" revenues and possibly antagonizing private-practice colleagues, rather than building their practices and participating in academic pursuits. I questioned these young colleagues' wisdom in passing judgment in areas where their expertise might well be limited.

This philosophy had, of course, no bearing on doctors in the community passing judgment on us. Many of us who thought we were acknowledged in the field to have sub specialist expertise have experienced the indignity of having a less-experienced generalist pass judgment on our care, possibly terminating it and leaving nothing further for the patient. Non experts in complex cases will make decisions on the basis of a single visit and superficial examination, often negating months of effort with a quick decision and the flourish of a pen.

I recall the case of a worker receiving treatment for an anterior cruciate-deficient knee. Rehabilitation had failed, and the treating sports medicine expert was about to proceed with a surgical reconstruction. The independent examiner, unfriendly to the treating physician, declared the procedure unnecessary, adding that such procedures were rarely indicated. Clearly, this is an out- dated concept rendered as an emotional decision. A patient of mine with very clear-cut signs of a nerve entrapment syndrome, failed conservative treatment, had negative electro diagnostic studies, but attained a successful outcome from surgery. A year later, the opposite extremity became symptomatic, with the same presentation. In this case, an examiner reported that surgery was not warranted. Since we had reached the end of efforts to relieve her symptoms conservatively and she was unable to work, we had a dilemma. She could not afford to pay for the surgery herself, and no hospital would accept her without a guarantee of payment.

I cannot condone the current IME system. If an insurance company wants another opinion, even multiple opinions by true experts in the field, so be it. But to denigrate the care of a competent doctor on the basis of an inexpert opinion, which has possibly been biased, is truly a scam perpetrated by companies who do not wish to honor their financial commitments and by their accomplices, physicians who, perhaps unwittingly, play the game. This practice needs significant reform.