AMA Guides® Newsletter - Issue Archive

Articles

1. Acromioclavicular Joint Arthritis

   Charles N. Brooks, Christopher R. Brigham

   Pages 1–3, 12

   DOI: 10.1001/amaguidesnewsletters.2005.SepOct01

   Abstract

   Acromioclavicular joint (ACJ) arthritis is a common source of shoulder pain. Manifestations of the arthritis may include inferiorly projecting spurs that predispose an individual to impingement and rotator cuff tears and can result in permanent impairment due to shoulder weakness or motion loss. Rotator cuff tendinopathy generally is multifactorial, and tears usually result from a combination of intrinsic factors (loads transmitted, local blood supply, and age) and extrinsic factors (impingement, primarily). Surgery to eliminate impingement collectively is termed subacromial decompression. The AMA Guides to the Evaluation of Permanent Impairment provides no impairment rating for cheilectomy about acromioclavicular or other joints, and, because removal of this liability is beneficial, it results in no (and perhaps even negative) impairment. An individual whose job involves repetitive shoulder elevation and who develops impingement probably has a legitimate workers’ compensation claim, even if predisposed by preexisting bony prominences; in this scenario, the proximate cause was repetitive shoulder elevation. A case example demonstrates that if an individual with preexisting osteoarthritis of the ACJ is injured and disabled at work, the rotator cuff tear, although preexisting, was worsened during employment and probably will be covered under the claim. In legal terms, findings of disability associated with ACJ injuries may differ depending on the jurisdiction.
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2. Questions and Answers: Pain-Related Impairment Questions

   Christopher R. Brigham

   Pages 4–5

   DOI: 10.1001/amaguidesnewsletters.2005.SepOct02

   Abstract

   Physicians who perform impairment evaluations should base their ratings on the objective condition of the patient, along with credible subjective findings. In making interpretations and judgments, examiners have obligations that are distinct from the duty of care as a treating physician. An experienced attending clinician, for example, may be unfamiliar with the correct process of rating impairment or may not feel unbiased in performing the rating. If significant new diagnoses are discovered, the physician has a medical obligation to inform the requesting party and individual about the condition and to recommend or refer for further medical assessment. When the physician is uncertain about which method to use to calculate an impairment rating or if more than one method can accurately be used, the physician should calculate the impairment rating using different alternatives and choose the method or combination of methods that best represents the functional impairment of the individual. The attending physician often is the person most knowledgeable about the injured employee and is encouraged to render the final impairment rating, when possible. Depending on the jurisdiction, examiners may be required to comply with specific constraints and duties regarding the rating. Examiners should not question an individual's integrity but can appropriately comment on the person's credibility.
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3. Special Features: Duties of the Examining Physician

   Alan Colledge

   Pages 6–6

   DOI: 10.1001/amaguidesnewsletters.2005.SepOct03

   Abstract

   Workers’ compensation systems provided $25.3 billion of compensation benefits in 1999, and nearly $19 billion of this was compensation for permanent injury. Under workers’ compensation, when injured worker have missed a predetermined amount of work time, they are eligible for wage indemnification (the amount is determined by the jurisdiction). Benefits continue until the disabling condition either permits a return to work or reaches a plateau at which healing ends and no significant improvement is likely (maximum medical improvement or a permanent and stationary condition). How the award is calculated differs from jurisdiction to jurisdiction: In some jurisdictions, permanent injury benefits are awarded only on the direct physical loss; other jurisdictions compensate to some degree for expected wage loss, loss of employment options, expenses for accommodating the disability, and, perhaps, an implicit award for psychological loss and pain. Some jurisdictions require all impairments to be combined as a single whole person impairment, but others use individual impairments expressed as a regional impairment. In some jurisdictions, the permanent benefit is statutory and has no medical or clinical basis (eg, some statutes limit or disallow awards for conditions such as tinnitus or certain psychological conditions). Evaluators must be aware of statutes, administrative rules, and case law that apply to the evaluation.
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4. Special Features: Workers' Compensation Benefits

   Alan Colledge, Greg Krohm

   Pages 7–7, 11

   DOI: 10.1001/amaguidesnewsletters.2005.SepOct04

   Abstract

   The AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides) specifies that impairment evaluation may be conducted by a treating or nontreating physician. A treating physician who is knowledgeable about the use of the AMA Guides may be the appropriate professional to evaluate impairment, but in cases that involve pain, disability, and medicolegal (forensic) issues, a truly independent medical examiner typically is most appropriate. All specialties share the same elevated risk of iatrogenesis when treating and evaluating/forensic roles are mixed because mixing compromises the quality of care and threatens the viability of the therapeutic relationship. Further, all treating specialties share the same bias toward offering treatment for most complaints—rather than engaging in the type of cautious skepticism that is required for competent impairment evaluation and other forensic duties. Finally, no treating clinician, regardless of specialty, can offer allegiance to judicial and administrative decision-makers. Treating clinicians often find themselves in a position in which they would be cutting off a source of their own income if they were to offer opinions that the clinical presentation is not valid, work related, or injury related, nor is the patient in need of further treatment. Such a financial conflict of interest can be eliminated only by referral to independent examiners and restricting treating clinicians from becoming involved in such decisions.
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5. Impairment Tutorial: Who Is in the Better Position to Evaluate, the Treating Physician or an Independent Examiner?

   Robert J. Barth, Christopher R. Brigham

   Pages 8–11

   DOI: 10.1001/amaguidesnewsletters.2005.SepOct05