AMA Guides® Newsletter - Issue Archive

Articles

1. The Intersection of Medicine and Disability

   Marcos Iglesias

   Pages 3–8

   DOI: 10.1001/amaguidesnewsletters.2018.JulAug01

   Abstract

   Many physicians were not formally trained in the evaluation and management of disability and must understand the language of disability, how disability is evaluated, what to expect from a medical evaluation, and how to communicate effectively to achieve the best outcomes. The very language of disability is complex and often is misunderstood. For example, the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, defines impairment as “a significant deviation, loss, or loss of use of any body structure or body function in an individual with a health condition, disorder, or disease.” In contrast, disability is variously defined by the administrative or legal system with jurisdiction, and the AMA Guides broadly defines disability as “activity limitations and/or participation restrictions in an individual with a health condition, disorder, or disease.” Another useful concept is “needless disability” or days away from work that are not medically necessary; workless populations experience a two- to threefold increased risk of poor general health, including higher rates of cardiovascular disease, lung cancer, and respiratory infections, among other problems that contribute to an excess mortality of 20% among individuals in this group. Physicians help establish but are not the final arbiters of disability determinations; their role is to provide accurate, complete, and clear information that allows others to determine the presence, extent, and compensability of disability.
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2. Pelvic Impairments

   James Talmage, Jay Blaisdell

   Pages 9–10

   DOI: 10.1001/amaguidesnewsletters.2018.JulAug02

   Abstract

   Pelvic fractures are relatively uncommon, and in workers’ compensation most pelvic fractures are the result of an acute, high-impact event such as a fall from a roof or an automobile collision. A person with osteoporosis may sustain a pelvic fracture from a lower-impact injury such as a minor fall. Further, major parts of the bladder, bowel, reproductive organs, nerves, and blood vessels pass through the pelvic ring, and traumatic pelvic fractures that result from a high-impact event often coincide with damaged organs, significant bleeding, and sensory and motor dysfunction. Following are the steps in the rating process: 1) assign the diagnosis and impairment class for the pelvis; 2) assign the functional history, physical examination, and clinical studies grade modifiers; and 3) apply the net adjustment formula. Because pelvic fractures are so uncommon, raters may be less familiar with the rating process for these types of injuries. The diagnosis-based methodology for rating pelvic fractures is consistent with the process used to rate other musculoskeletal impairments. Evaluators must base the rating on reliable data when the patient is at maximum medical impairment and must assess possible impairment from concomitant injuries.
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3. Somatization

   Leon Ensalada, Christopher R. Brigham, Les Kertay

   Pages 11–13, 16

   DOI: 10.1001/amaguidesnewsletters.2018.JulAug03

   Abstract

   An evaluator's failure to recognize illness behavior and to adjust for its effect on symptom presentation can lead to erroneous conclusions regarding impairment or disability; here the authors review the associated phenomena of somatization, disorders that arise from it, and factors that contribute to somatization. Somatization is an individual's unconscious use of the body or bodily symptoms for psychological purposes or psychological gain. As the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, notes, somatization is a “tendency to experience and report somatic complaints (physical symptoms) in response to psychosocial stress and seek health care services for them.” The AMA Guides also advises evaluators that “exclusion or inclusion of somatization disorder, factitious disorder, and/or malingering must be done with care.” A table lists developmental factors that may dispose to somatization (eg, somatizers are present in the family of origin, or coping mechanisms other than illness behavior are absent or unacceptable); a second table compares disorders that may involve somatization. Somatization is prevalent in clinical practice and is likely to occur with equal, or higher, frequency in the evaluation setting. The presence of somatization distorts symptom presentation and can exert a confounding effect on impairment assessment methodologies that rely on the accuracy of patients’ self-presentations.
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4. Illness Behavior

   Leon Ensalada, Les Kertay

   Pages 14–15

   DOI: 10.1001/amaguidesnewsletters.2018.JulAug04

   Abstract

   Illness behavior refers to the ways in which given symptoms may be perceived, evaluated, and acted on by different persons and can be conscious or unconscious (the latter means unnoticeable and refers to mental processes and content that are significant in determining behavior but of which the person is unaware). Further, consciousness of actions (voluntariness) and consciousness of motives (intentionality) are not necessarily associated. Illness behavior can be learned and reinforced and is a potential confounder in the association between illness or injury and impairment or disability. Illness behavior is not an impairing condition according to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), and a table in the article describes the characteristics of the symptom magnification syndrome and other related conditions. Three diagnoses—somatic symptom disorders, illness anxiety disorder, and conversion disorder—possibly are ratable using the AMA Guides. Unsupported and insupportable conclusions regarding symptom exaggeration represent substandard practice because of the importance of such conclusions to the disposition of patients who present for assessment of impairment or disability. Similarly, failure to note and account for illness behavior and symptom exaggeration also represent substandard practice because the goal in impairment ratings is to note and account for all evidence related to the impairment, including the extent of illness behaviors.
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