AMA Guides® Newsletter - Issue Archive

Articles

1. The Independent Medical Evaluation Relationship

   Jack Richman

   Pages 1–4

   DOI: 10.1001/amaguidesnewsletters.2003.MayJun01

   Abstract

   According to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, an independent medical evaluation (IME) is “an evaluation performed by an independent medical examiner, who evaluates—but does not provide care for—the individual.” In April 2002, the Work Fitness and Disability Evaluation Section of the American College of Occupational and Environmental Medicine (ACOEM) prepared a motion defining the rationale why there is no a priori establishment of a patient–physician relationship during an IME. A figure in the article includes the text of the resolution, which was proposed and debated at the House of Delegates but has not yet been adopted by ACOEM. A table prepared by the College of Physicians and Surgeons of Ontario (CPSO) enumerates differences between the usual doctor–patient relationship and IMEs in terms of duty to provide care, maintaining records, access to records, and fees. CPSO also clarifies that physicians who agree to conduct third-party examinations of individuals whom they are not currently treating have been hired by a third party to perform a particular task, typically to provide an opinion or answer specific questions about the individual. Clear and effective communication with the individual are particularly important because the individual's livelihood or compensation for injury, as well as the person's continuing health, are at stake.
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2. Impairment Tutorial: Impairment Classes and Ranges

   Christopher R. Brigham, Kathryn Mueller

   Pages 4–10

   DOI: 10.1001/amaguidesnewsletters.2003.MayJun02

   Abstract

   Many chapters in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) provide a range of numbers within four or five impairment classes, and evaluating physicians are required to justify the choice of a class and the impairment rating within the range specified for that class. The process of assigning a class is accomplished by an assessment of the patient's disease process, objective findings, activities of daily living (ADLs), and required continuing medical treatment. A table in the article provides hyperlinks to different scales for measurement of instrumental activities of daily living and ADL; use of these standardized instruments increases the reliability of assessing the impact on ADLs. After describing the patient's ability to perform ADLs, the evaluating physician should ensure that the physical examination and laboratory findings lead to the final diagnosis used for rating. To provide an impairment rating, the evaluator must identify and confirm a physiologic abnormality via physical examination or laboratory or x-ray findings consistent with the diagnosis. Impairment rating must be based on a clearly established diagnosis, not solely on subjective complaints from the patient. As with all impairment evaluations, the rating should be based on a thoughtful evaluation and obtaining the data needed to apply the criteria specified in the AMA Guides.
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3. Questions & Answers

   Pages 6–10

   DOI: 10.1001/amaguidesnewsletters.2003.MayJun03

   Abstract

   The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Chapter 3, The Heart and Aorta, is used to rate impairment in patients with coronary disease. Note that the four “functional classes” of the New York Heart Association, which are discussed in the chapter, should not be confused with the four classes used to rate impairment due to coronary heart disease. Treadmill testing of maximal exercise ability is a traditional measurement to help the evaluator place an individual in an impairment rating class. Class 1 impairment rarely is used in rating workers’ compensation impairment, and the presence of small (asymptomatic) coronary artery blockages that may progress is the justification for considering these individuals impaired even in the absence of symptoms. Classes 2, 3, and 4 describe the impairment of individuals with objectively documented symptomatic coronary disease. Class 2 impairment describes individuals who have no symptoms or who manage them with diet or medication and can achieve 90% of predicted maximal heart rate during exercise testing without specific signs of ischemia. Class 3 impairment describes individuals who have symptoms of congestive failure or angina with moderately heavy activity, and Class 4 includes individuals who have symptoms during ordinary activity. To give guidance in this process, a series of clinical examples follows the description of each class.
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4. Impairment Tutorial: Impairment from Coronary Artery Disease: Fifth Edition Approach

   James B. Talmage, Christopher R. Brigham

   Pages 8–9

   DOI: 10.1001/amaguidesnewsletters.2003.MayJun04

   Abstract

   Before the publication of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, each chapter focused on a single organ system and provided a description of the diagnostic and evaluative methods for assessing impairment at the organ system level and functional impairment of the whole person. Beginning with the Fourth and continuing into the Fifth Edition, a new chapter focused not on a single organ system but rather on pain. The author of this article takes issue with others who propose that pain should not only be conceptualized as a disabling factor but also as an impairment. Some have argued that, “[d]espite its stated intent, the [AMA] Guides does not maintain a clear focus on functional impairment … it blurs the line between impairment and disability. The [AMA] Guides defines impairment so broadly as to include disability, effectively confusing the 2 concepts.” For these very reasons, argues the author of this article, pain should not be conceptualized as an impairment, and rating schemes should not promote or reinforce inappropriate behavior, for example, by providing a reward for reporting more pain. The latter will lead to more diagnostic testing, more treatment, and more physician-prescribed work absence, culminating in the reinforcement of perceived illness and incapacity.
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5. Clinical Update: Pain: Impairment vs Disability

   Leon H. Ensalada

   Pages 11–12

   DOI: 10.1001/amaguidesnewsletters.2003.MayJun05