• The Medical History: "Found Down, On Fire"

    01 December 2011 / Medical History / Comments Off on The Medical History: "Found Down, On Fire"

    “Found down on Fire?!” I asked. “Really? That was it?!” I demanded.

    “Yes.”, answered The Captain, and he took another sip on his cocktail. He was calm and very comfortable in the San Diego evening. The tropical shirt on his chest was adjusted to allow more exposure to the sun as it went down over the Pacific. A small grin stole across his mustachioed face. I realized I was in the presence of a genius.

    The Captain, as I call him, is arguably the best trauma surgeon in Southern California. He had done his training at L.A. County Hospital. We had just finished a discussion on the best authored medical histories of our careers. Of course he had won…and knew it.

    This was several years ago now, but each time I set down to put pen on paper I think about the wisdom of this simple medical history that has withstood the test of time. In my opinion, “Found down on Fire” has no equal. It is a timeless classic in the “Medical History Hall of Fame” because it is the definition of simple and complete in its description. A little “too descriptive” according to some of my other colleagues, but no one has questioned it authority.

    I wanted to use this story to underscore the significance of being short and descriptive in the medical history component of the medical legal report. I think everyone can agree that it is much easier to write a long, rambling medical introduction and avoid the discipline and energy it takes to work with economy. If we were to open a medical chart on any teaching hospital service, you would find a five page note from the medical student, a one page note from the resident physician, and a one line note from the attending physician. Why? The attending physician understands the command of the language, and how to communicate the most information with the fewest words. Sound simple? Well, it isn’t. It is not until you have written pages and pages of histories that you are prepared and qualified to write a shorter, succinct history. Like anything else, it takes time to learn what is important in a history, and what is not.

    The medical history is where the whole thing starts…literally. The history is the reason that the claim is here in the first place. After years of reading, writing and thinking about the medical legal history, the best medical history is one that gives character and life to the description of the injury. The Captain impressed this upon me. To be a great history, the description of the injury must be accessible to all readers of the report, and leave no room for doubt as to the applicant’s description of the injury.

    Traditionally the doctor is taught to take the history in a standard, very predictable way. When did the symptoms start? What were you doing when the symptoms started? What makes the symptoms better? What makes the symptoms worse? What other symptoms do the primary symptoms cause? How often are the symptoms present? And this standardized approach definitely has its place. But what about this?

    How many reports have you read that began innocent enough, only to morph into a massive, confusing novel of epic proportions? A report that is well intended, can actually leave you frustrated and reaching for a bottle of aspirin by the fifth or twenty fifth paragraph? I have read a few of these. Actually, I have read more than a few of these.

    As a doctor writing a medical legal report, my goal is pretty clear: Does this story make any medical sense? Do I believe what I am writing? Can I explain myself to the claims adjuster or the attorney who is going to pick up and read this report? If it is clear and simple enough, I won’t have to do any explaining because the report will speak for itself. This is the goal!

  • I’ve Got You Under My Skin: The Impairment Physical Exam

    29 November 2011 / Impairment Physical Exam / Comments Off on I’ve Got You Under My Skin: The Impairment Physical Exam

    In honor of my wife, who is a California QME Occupational dermatologist, a few comments on skin impairment rating exams are indicated here. The skin exam an important and frequent focus of impairment rating in a general impairment practice. The area examined needs to be clearly communicated to the reader as to the extent and scope performed.

    I especially favor descriptions such as face, upper trunk, waist up, or total body skin screening. Included in the description should be the type of skin (Type 1 (light)-4 (dark)), the amount of photo damage, the hair and eye color, surgical repair scars, actinic damage, and basic descriptors of lesions such as “pigmented”, “raised”, “ulcerated”, “blistered”, “scale”, “erythema” or “vascular mat or telangectasia” are just a few of my favorites.

    Plaques or papules can be used to describe raised lesions. The measurement of the lesion or field can be recorded by cm, mm, or percent of body surface area (%BSA). A simple rule of thumb I like is 1% BSA is roughly equal to the size of a hand. When appropriate, include the quality of the hair and nails, moisture patterns, and hair distribution loss which are important findings in many systemic disease processes such as psoriasis, iron deficiency, or autoimmune reactions.

    Remember, a careful skin and nail examination is also critical in the evaluation of chronic regional pain syndrome (See page 496, Table 16-16, Chapter 16, The Upper Extremities, AMA Guides 5th Edition, AMA Press, 2004 for diagnostic criteria).

  • Preparing for the Independent Medical Exam

    17 November 2011 / Impairment Physical Exam / Comments Off on Preparing for the Independent Medical Exam

    The AMA Guides 5th Edition have work tables at the end of each orthopedic chapter to organize the exam. If you are new to the report writing business, I suggest the reader take time and carefully look over these comprehensive templates. Use these templates for your first several exams to insure you do not leave out important measurements in the exam.

    As you increase your number of exams, I have found it most beneficial to edit down these templates to suite my exam style. Regardless of which approach used, the goal is to standardize the collection of your measurements in a way that will expedite the writing of the report and impairment calculations in a manner that the reader can easily follow your steps, and if necessary, another physician can reproduce.

    Key to success

    Keep in mind the ratable findings and measurements before preparing for the exam-- example: knee crepitus with a history of direct blow trauma is ratable is ratable (page 544, Chapter 17, The Lower Extremities Table 17-31 footnote, AMA Guides 5th Edition, AMA Press, 2004).

    This positive or negative finding would be specifically reported in the exam.

  • The Impairment Physical Exam

    15 November 2011 / Impairment Physical Exam / Comments Off on The Impairment Physical Exam

    The goal for the impairment physical Exam:

    A Complete, logical, systematic collection of physical measurement data.

    Do the exam the same way every time to avoid missing important measurements or key elements of the exam. A full and complete exam is necessary to demonstrate a thorough exam and support billing codes. A properly performed examination will add credibility to your opinions and conclusions.

    Remember, the AMA Guides 5th Edition is based on findings that can be seen, measured, and touched. A simple rule of thumb, if you can walk out of the exam room, and another doctor can walk in and reproduce your findings, you have an objective physical exam.

    This is easier said than done, but with practice and being aware of your physical exam language, this talent can be quickly learned. Review anatomical landmarks to reference exam areas.



  • Impairment Rating Specialists

    07 November 2010 / Impairment Rating Specialists / Comments Off on Impairment Rating Specialists

    Announcing a new partnership with one goal… Making California’s Workers’ Compensation Work.

    Dr. John Alchemy M.D. of Impairment Rating Specialists and Phil Walker Esquire of Walker Companies are pleased to announce their new partnership. Their aim of this partnership is simple….provide correct AMA reports and results for injured workers and the California Workers’ Compensation industry.

    Each year millions of dollars and valuable employee time is spend on delays and incorrect reports. Eighty percent of California impairment reports are wrong, and we have now begun work to correct this problem. We would like you to join us!

    Impairment Rating Specialists and Walker Companies are innovators in impairment evaluations, report design and developing standards for objective, correct and reproducible reports. We work tirelessly every report, every day, every opinion with one goal…We want to make California’s Workers’ Comp Work.

    Together Dr. John Alchemy and Phil Walker have over 35 years combined experience in the field of California workers comp and have reviewed and written well over 15,000 reports and AMA ratings.

    Dr. John AlchemyDr. John Alchemy is founder and CEO of Impairment Rating Specialist. He has been practicing Occupational and Family Medicine since 1997, and is a diplomat of the American Board of Family Practice. Dr. Alchemy is a “Certified Independent Medical Evaluator” (CIME) endorsed by the American Board of Independent Medical Examiners (ABIME), an international standard that verifies AMA Guides competency. Dr. Alchemy has certificates of education from the American Association of Medical Review Officers (AAMRO) and is also a California Qualified Medical Examiner (QME). Dr. Alchemy has directed multiple occupation medicine centers in California and has served as a utilization reviewer in the industry for several years. Dr. Alchemy remains active in clinical claim management, in addition to directing Impairment Rating Specialists as we grow our presence in the California Impairment Rating market.

    Phil Walker, Esq.Phil Walker, Esq., owns Walker Companies, a California Law Corporation that offers AMA report review services to California’s largest businesses (Macy’s, UC California, Wal-Mart). Report review services insure physician rating reports are legally compliant with the AMA Guides. Mr. Walker is an educator, professional speaker, author and AMA Guides expert well recognized in California. He is a member of the bar in California, New York, and the District of Columbia. Walker Companies perform comprehensive legal services and consulting for employers, physician practices, and insurance carriers who want to improve their standards of care, and place high value on returning injured workers to their jobs.

    Dr. John Alchemy M.D. and Phil Walker Esquire will be providing regular blogs on the Impairment Rating Specialist website. Dr. John Alchemy and Phil Walker will also be offering Twitter updates for those who would like constant valuable updates on common medical conditions and impairment rating tips with practical applications. You can follow them on Twitter at @ImpairmentRate.

    They are also pleased to announce the partnerships of additional doctors with specialties including orthopedics, sports medicine, dermatology, psychiatry, chiropractic and acupuncture. These doctors, and our growing community of partner specialists, will be profiled in upcoming blog entries as well as featured as guest bloggers in upcoming entries.

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