• Medical Imaging & Diagnostic Tests in Chart Reviews

    17 September 2012 / Chart Reviews / Comments Off on Medical Imaging & Diagnostic Tests in Chart Reviews

    Medical imaging and diagnostic testing reports are of great interest. These reports are strictly objective.

    Check the reason for the ordering of the test. This is usually a one to two sentence statement. Check any diagnostic imaging prior that is used for comparison in the conclusions. Again, do the findings support the diagnoses? Has the imaging ruled in or out any diagnoses, you may have in your mind as you read the record?

    Remember, as you review medical imaging and diagnostic testing reports, are there any missing tests that would be critical for you to determine a diagnosis?

    If you're reviewing, diagnostic tests, such as laboratory data, be sure to include normal range values. The reader may not know the normal ranges, or normal may vary from lab to lab.

    I review laboratory results as "normal", "abnormal elevated", "abnormal low”, and "borderline high or low". If the laboratory value is going to play a critical role in my opinion, I will of course dictate the exact numeric value.

    Search the chart for specific labs. For example, the hemoglobin A1c in diabetics when the case involves a nerve condition, i.e.carpal tunnel syndrome.

    If such information is lacking in the medical record, be sure to comment on it and its significance in your discussion. The same is true with diagnostic tissue pathology. Example, if you're a dermatologist, confirmatory biopsies are critical in formulating a working diagnosis.

    If a diagnosis needs to be made by tissue and is not included in the chart documents, be sure this is highlighted in your discussion.

  • Effects of Treatment or Lack of Treatment

    13 September 2012 / Impairment Rating Specialists / Comments Off on Effects of Treatment or Lack of Treatment

    If treatment of an illness produces total remission of the signs and symptoms (for example, a diabetic treated with insulin) but the illness is not cured, then the physician may increase the impairment by 1% to 3% WPI.

    If the treatment or medication leads to the impairment (example: immune-suppressing drugs for organ transplant), the evaluator should rate such impairment.

    If the patient declines treatment for a medical condition, that does not increase or decrease the estimated percentage of impairment for the condition.

    A physician should comment on:

    • Whether the treatment is appropriate, and
    • Basis for the patient's declining treatment, and
    • Whether the impairment is at maximum medical improvement without the treatment, and
    • May estimate what the impairment would likely be with the treatment

     

    (Sec. 2.5g AMA Guides to the Evaluation of Permanent impairment [Fifth Edition])

  • Defining Work Restrictions, Capacity & Limitation

    10 September 2012 / California Workers Compensation / Comments Off on Defining Work Restrictions, Capacity & Limitation

    As doctors, we have all gotten the phone call from the either the employee or the employer asking for clarification on what the employee can and cannot do.

    Often the indications for the recommended work functions are unclear, poorly described, or simply left up to the employee and the employer to figure out how to best “get along”.

    The problem with this any of these options is that they leave the interpretation and necessity for work functional limitations up to interpretation. Employees and employers frequently look to us to guide the rehabilitation process, and clearly outlining the employees duty is central to that service.

    The employer wants a safe return to work environment, and needs specifics to determine if return to work accommodations can indeed be made. The employee is concerned about worsening of symptoms or anticipated worsening of symptoms.

    The following “word of art” discussion will aid the medical provider in clarifying the intent and medical necessity of outlining return to work instructions for the injured worker.

     

    Work Restrictions:

    The word work “restriction” implies that a measure of safety for the employee or the co-workers are dependent on following the instructions.

    The restriction may very well be a function that the employee is capable of performing, BUT SHOULD NOT PERFORM with the risk of personal injury or injury to a co-worker.

    An excellent example of a work restriction are the instructions provided for an employee with a seizure disorder not to drive or perform safety sensitive work.

    If the employee were to drive and have a seizure, the consequences would be disastrous (for the employee or co-workers riding with the employee).

     

    Work Limitation:

    A limitation suggests that the employee cannot perform an activity as “a result of an illness or an injury” (p 121). An example of this is a worker who has had a right shoulder injury with adhesive capsulitis, firm end range of motion endpoints and capsular thickening on MRI imaging that supports the diagnosis. As a result the worker can no longer raise their shoulder above the level of the shoulder plane. The key when thinking about the use of this term is that the limitation is “measurable or objectifiable” (p 121). In the example of this worker, the shoulder has an identifiable underlying medical condition that explains and supports the limitation. The shoulder has scarred, and a reproducible measurable loss etc. The worker has a “limitation” that precludes at or above right shoulder level work. Of note, the work limitation should “be proportional” to objective findings” (p 131).

     

    Work Tolerance:

    Tolerance is by far the most common reason for assigning functional work instructions. “Tolerance is apsychophysiologic concept. It is the ability to tolerate sustained work or activity at a given level” (p 10).

    The ability for two doctors to have agreement on issues of work restrictions and limitations are reasonably good, however, the ability to agree on issues of tolerance is much less, because of the subjective nature of the complaints and lack of objective findings.

    When the subjective complaints are grossly inconsistent with the physical findings and objective imaging, however, most physician can at least agree that work activity poses no “risk” and has no clear “limitation”. In this situation, the doctor often finds him/herself functioning more as a secretary, rather than a doctor, as there are no underlying identifiable conditions.

    When trying to assess “tolerance” it is important to review with the worker what they are and are not capable of performing not only at the workplace, but also at home.

    The worker who presents to the clinic stating she cannot lift anything of weight, yet is carrying a six pound purse over her shoulder with apparent ease needs to be redirected in her assertions of tolerance and reasonable expectations based on the objective findings of the physical exam and imaging.

  • Ligaments & Permanent Impairment

    07 September 2012 / Impairment Rating Specialists / Comments Off on Ligaments & Permanent Impairment

    A ligament is a soft, fibrous tissue structure that connects bone to bone to form a joint. A ligament differs from a tendon, which connects muscle to bone.
    Injury can occur when a ligament becomes stretched, partially torn, or completely disrupted. The injury can range from a minor strain to complete disruption of all fibrous tissue. Serious cases of injury may result in instability of the joint, significant bleeding, chronic pain, and swelling. Most ligament injuries can be diagnosed by an X-ray or MRI scan and treated with conservative measures such as ice, rest, compression, and limited bracing.

    When a ligament overlies a joint, it may become difficult to determine if pain and symptoms are due to a ligament injury or an underlying joint injury. In certain instances such as a knee injury, the tendon and joint cartilage may be injured at the same time. Injuries that do not respond to conservative care may require additional imaging by an MRI and/or referral to an orthopedic specialist.

    • A ligament connects bone to bone.
    • Treatment is usually conservative. If the condition fails to improve, additional imaging by an orthopedic specialist may be indicated.
    • Caution must be taken when diagnosing an injury that involves a ligament overlying a joint. Consideration must be given for a possible deep joint or cartilage structure injury.

    Rating Comment: The AMA Guides to the Evaluation of Permanent Impairment Fifth Edition provides impairment rating for ligament instability/injury in the shoulder and wrist, Chapter 16: Upper Extremities and in the knee, Chapter 17: Lower Extremities. Additional impairment rating may also be assigned in some circumstances for ligament injuries that impair range of motion.

  • Taking the Medical Impairment History Interview

    04 September 2012 / Medical History / Comments Off on Taking the Medical Impairment History Interview

    Lay the ground rules for the exam before you start the interview:

    1. The answers are to only be provided by the employee.

    2. The interviewer is not a treating provider and there is no doctor patient relationship. Make sure the patient understands this before you begin, otherwise they will continue to ask you questions as a primary treator.

    3. Information shared in the interview will be included in the report and communicated with all parties. If the employee chooses not to answer a question they need to state so, and the interviewer will move on to the next question.

    4. At any time in the interview or exam, if the employee experiences pain they are to stop any painful activity immediately and notify the examiner.

  • Getting Almaraz-Guzman II Ratings Correct

    31 August 2012 / Impairment Rating Specialists / Comments Off on Getting Almaraz-Guzman II Ratings Correct

    California was the 44th state in America to adopt the AMA Guides for calculating permanent impairment. In fact, this book is the most widely used book in the world for calculating permanent impairment. It is used in all Commonwealth countries, many Federal compensation systems, and in auto accident cases in some states.

    Why has this book become the most widely used book for calculating impairment in the world? Because it is based on one simple idea: 2 doctors, looking at the same patient at about the same time and getting the same results, should come up with the same impairment rating. Pretty simple, huh? It says: 2 + 2 should equal 4 each time.

    In order to do that, physicians must look at the same things and measure them the same way. These are called objective factors of impairment.

    Let me give you an example: If my arm were cut off at the elbow, shouldn't every doctor measuring that be able to measure it the same way and come up with the same result. Yes, and yes. If one doctor said 50% of the arm were cut off, and another said only 10% was cut off, we would say that is wrong, wouldn't we? Yes, and yes.

    So, the Guides give doctors things to measure and tell them how to measure them. The goal is for all doctors to be able to calculate impairment the same way by looking at the same body parts and measuring them the same way.

    For those of us in California, the concept of two doctors coming up with the same permanent impairment rating is hard to get our minds around because our entire workers' compensation system has been built on two doctors looking at the same patient and coming up with different impairment numbers. Kind of like saying, Dr. A looks at my arm and says 50% is cut off. Dr. B looks at my arm and says only 10% is cut off? Can both of them be correct? No. But, for 50 years in California, instead of saying that one of the doctors was wrong, we would split it in the middle to get the case settled. Kind of crazy, but that is what happened.

    California adopted the AMA Guides in 2004 in an effort to end that. The purpose of adopting the Guides was to get correct impairment ratings. Period.

    After the Guides were adopted in California, various legal challenges were launched to them in an effort to get rid of them. All of those challenges lost. The Guides were found to be Constitutional, and the Legislature was found to have the power to adopt them to measure impairment ratings.

    And, for a period of about 6 months, we began to get impairment ratings which were correct under the Guides. When I say correct, here is what I mean: 2 + 2 = 4. Not 5 or 1,000. It is just like grading a test. If you were asked what 2 + 2 equals and you answered "4," your answer is correct. If you answered "1,000," your answer is wrong. Because 2 + 2 = 4 every time.

    And every challenge to the Guides lost, until one: Almaraz-Guzman II.

    See tuned for the next blog for the rest of the story.

  • Medical Imaging & Diagnostic Tests

    27 August 2012 / Chart Reviews / Comments Off on Medical Imaging & Diagnostic Tests

    Medical imaging and diagnostic testing reports are of great interest. These reports are strictly objective.

    Check the reason for the ordering of the test. This is usually a one to two sentence statement.

    Check any diagnostic imaging prior that is used for comparison in the conclusions. Again, do the findings support the diagnoses? Has the imaging ruled in or out any diagnoses, you may have in your mind as you read the record?

    Remember, as you review medical imaging and diagnostic testing reports, are there any missing tests that would be critical for you to determine a diagnosis? If you're reviewing, diagnostic tests, such as laboratory data, be sure to include normal range values.

    The reader may not know the normal ranges, or normal may vary from lab to lab. I review laboratory results as "normal", "abnormal elevated", "abnormal low”, and "borderline high or low". If the laboratory value is going to play a critical role in my opinion, I will of course dictate the exact numeric value.

    Search the chart for specific labs. For example, the hemoglobin A1c in diabetics when the case involves a nerve condition, i.e.carpal tunnel syndrome. If such information is lacking in the medical record, be sure to comment on it and its significance in your discussion.

    The same is true with diagnostic tissue pathology. Example, if you're a dermatologist, confirmatory biopsies are critical in formulating a working diagnosis. If a diagnosis needs to be made by tissue and is not included in the chart documents, be sure this is highlighted in your discussion.

  • Brief Summaries of the Definitions of Work Restrictions, Capacity & Limitation

    23 August 2012 / California Workers Compensation / Comments Off on Brief Summaries of the Definitions of Work Restrictions, Capacity & Limitation

    The following is a summary to clarify the often confusing terms of work functional restrictions and limitations. The summary below is a summary review from “A Physician’s Guide to Return to Work”, by authors James B. Talmage, MD and J. Mark Melhorn, MD, AMA Press, 2005. Chapter 9.

    This summary is designed to clarify the confusion that a primary treating physician often faces in making determinations in return to work and employer recommendations. In my experience I have found a great deal of confusion over the terms “restriction”, “capacity” and “tolerance”.

    Many of these terms are used interchangeably, sometimes on the same form. A firm understanding of these terms and definitions will help the medical providers and employers avoid unnecessary confusion, communicate more clearly, and improve overall satisfaction with clinical service and instructions.

    Work Restriction:

    A risk poses a life threatening or potential serious injury if not followed to the worker or co-worker. It does not imply an inability to perform a certain task or activity.

    Work Limitation:

    A limitation implies that a certain activity or function cannot be performed due to an indentified underlying condition supported by objective medical and/or imaging findings.

    Work Tolerance:

    A tolerance is a subjective report of symptoms that preclude the worker from performing a certain task or activity. A work tolerance is neither a restriction or a limitation, and determination can prove to be elusive inconsistent between medical providers. Tolerance represents the majority of challenge for providers by virtue of lack of objective findings.

  • Operative Notes in Chart Reviews

    20 August 2012 / Chart Reviews / Comments Off on Operative Notes in Chart Reviews

    The review of operative notes are of great value.

    In the body of the operative note, the surgeon will describe the actual findings. This report will include the condition of the tissues, actual evidence of trauma detectives and bone, and may also include ranges of motion while under anesthesia.

    Pay attention to the preoperative and postoperative diagnoses. Are they the same? If not, why?

    Was anything new discovered as a result of the surgery? Do the findings coincide with the level of subjective complaints?

  • Fit for Duty vs. Return to Work

    17 August 2012 / California Workers Compensation, Impairment Physical Exam / Comments Off on Fit for Duty vs. Return to Work

    Fit for duty is an exam when the employer has a suspicion that the employee may be exhibiting abnormal behavior such as under the influence of a substance, or injured (non industrially) in a way that may impair their ability to perform the job safely. Examples may include slurring speech, balance difficulty or limping. Are they "fit" for work?

    Return to work implies the employee has been absent from the workplace on a non-industrial basis and now need an evaluation to see if they can be safely re-integrated into the workplace. Examples include having missed work with an excused physician note due to an auto accident, an elective surgery, or an orthopedic fracture. Are they able to "Return to work"?

    It is critical that the employer has a very clear and consistent policy about how each exam is referred to the clinic, and it is always my recommendation that consultation is carried out with an attorney well-studied in the applicable labor codes and laws when considering a policy to exercise.

    These exams are in place to prevent further injury to employees and protect co-workers. The exams need to detailed, and multiple consents for exam and information must be obtained prior to the examination which explains the scope and extent of the information requested, and to whom it will be disclosed. 

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